Internet-delivered behavior change program increases physical activity and improves cardiometabolic disease risk factors in sedentary adults: results of a randomized controlled trial

Effectiveness of socioecological model-guided, smart device-based, and self-management-oriented lifestyle (3SLIFE) intervention on healthy lifestyles and metabolic syndrome risk in community residents: a cluster-randomized controlled trial

BACKGROUND

Mobile health (mHealth) lifestyle interventions have showed promise in improving healthy lifestyles and reducing metabolic syndrome (MetS) risk, yet most studies adopt isolated frameworks. The 3SLIFE model-integrating the socioecological model, smart devices, and self-management strategies-provides a holistic approach to sustained behavioral change. It considers environmental influences, empowers individuals in goal-setting and engagement, and leverages smart devices for monitoring and feedback. Despite its potential, evidence on this integrated approach remains scarce. This study applies 3SLIFE to community-dwelling adults, aiming to improve healthy lifestyles.

METHODS

In this parallel, cluster-randomized controlled trial, 20 communities in Southwestern China were randomly assigned 1:1 to either the intervention or control group. Participants in the intervention group received the 3SLIFE intervention for 6 months, while those in the control group received routine management. The healthy lifestyle score was calculated for each participant based on smoking, alcohol intake, physical activity, dietary habits, and overweight/obesity. The primary outcome was the change in the healthy lifestyle score at the end of the 6-month trial. Differences in the score between groups were estimated using generalized linear mixed-effects models in the intention-to-treat population at 3, 6, and 12 months of follow-up.

RESULTS

From April to July 2023, 383 community-dwelling adults (mean age: 57.64 ± 11.32 years; 42.30% male) were recruited-190 in the intervention group and 193 in the control group. After the 6-month intervention, the increase in the healthy lifestyle score was slightly higher in the intervention group (13.22 ± 3.30 to 13.40 ± 2.88) than in the control group (13.34 ± 3.10 to 12.79 ± 3.32), with a mean difference of 0.77 (95% CI, 0.17 to 1.38). A higher proportion in the intervention group reduced at least one unhealthy lifestyle compared to the control group (31.48% vs. 19.64%, P = 0.016). However, no significant difference in score change was observed between groups at 12-month follow-up.

CONCLUSIONS

This study provides evidence that the 3SLIFE intervention could modestly improve healthy lifestyles in a community-based population, but the effects were not sustained at the 12-month follow-up. A further refinement is needed to enhance the intervention's long-term effectiveness in promoting sustainable lifestyle changes and reduce MetS risk in communities.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2300070575.

The Influence of Physical Activity and Diet Mobile Apps on Cardiovascular Disease Risk Factors: Meta-Review

BACKGROUND

The literature on whether physical activity (PA) and PA and diet (PA+Diet) mobile apps improve cardiovascular disease (CVD) risk factors is promising.

OBJECTIVE

The aim of this meta-review is to provide an evidence synthesis of systematic reviews and meta-analyses examining the influence of PA and PA+Diet apps on the major CVD risk factors.

METHODS

We systematically searched 5 databases until January 12, 2022. Included systematic reviews and meta-analyses (1) reported the CVD risk factor outcomes of BMI, waist circumference, body weight, blood pressure (BP), hemoglobin A1c (HbA1c), fasting blood glucose, blood lipids, or PA; (2) enrolled healthy participants ≥18 years who may or may not have the metabolic syndrome, diabetes mellitus, or preexisting CVD risk factors; (3) reviewed PA or PA+Diet app interventions integrating behavioral change techniques (BCT) to deliver their information; and (4) had a nonapp control.

RESULTS

In total, 17 reviews (9 systematic reviews and 8 meta-analyses) published between 2012 and 2021 qualified. Participants were middle-aged, mostly women ranging in number from 10 to 62,219. Interventions lasted from 1 to 24 months, with the most common behavioral strategies being personalized feedback (n=8), self-monitoring (n=7), and goal setting (n=5). Of the PA app systematic reviews (N=4), the following CVD risk factors improved: body weight and BMI (n=2, 50%), BP (n=1, 25%), HbA1c (n=1, 25%), and blood lipids (n=1, 25%) decreased, while PA (n=4, 100%) increased. Of the PA+Diet app systematic reviews (N=5), the following CVD risk factors improved: body weight and BMI (n=3, 60%), BP (n=1, 20%), and HbA1c (n=3, 60%) decreased, while PA (n=3, 60%) increased. Of the PA app meta-analyses (N=1), the following CVD risk factors improved: body weight decreased (-0.73 kg, 95% CI -1.45 to -0.01; P=.05) and PA increased by 25 minutes/week (95% CI 0.58-1.68; P<.001), while BMI (-0.09 kg/m2, 95% CI -0.29 to 0.10; P=.35) and waist circumference (-1.92 cm, 95% CI -3.94 to 0.09; P=.06) tended to decrease. Of the PA+Diet app meta-analyses (n=4), the following CVD risk factors improved: body weight (n=4, 100%; from -1.79 kg 95% CI -3.17 to -0.41; P=.01 to -2.80 kg 95% CI -4.54 to -1.06, P=.002), BMI (n=1, 25%; -0.64 kg/m2, 95% CI -1.09 to -0.18; P=.01), waist circumference (n=1, 25%; -2.46 cm, 95% CI -4.56 to -0.36; P=.02), systolic/diastolic BP (n=1, 25%; -4.22/-2.87 mm Hg, 95% CI -6.54 to -1.91/ -4.44 to -1.29; P<.01), and HbA1c (n=1, 25%; -0.43%, 95% CI -0.68 to -0.19; P<.001) decreased.

CONCLUSIONS

PA and PA+Diet apps appear to be most consistent in improving PA and anthropometric measures with favorable but less consistent effects on other CVD risk factors. Future studies are needed that directly compare and better quantify the effects of PA and PA+Diet apps on CVD risk factors.

TRIAL REGISTRATION

PROSPERO CRD42023392359; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=392359.

The Regulate your Sitting Time (RESIT) intervention for reducing sitting time in individuals with type 2 diabetes: findings from a randomised-controlled feasibility trial

BACKGROUND

Reducing and breaking up sitting is recommended for optimal management of Type 2 diabetes mellitus (T2DM). Yet, there is limited evidence of interventions targeting these outcomes in individuals with this condition. The primary aim of this study was to assess the feasibility and acceptability of delivering and evaluating a tailored online intervention to reduce and break up sitting in adults with T2DM.

METHODS

A mixed-methods two-arm randomised controlled feasibility trial was conducted in ambulatory adults with T2DM who were randomised 1:1 to the REgulate your SItting Time (RESIT) intervention or usual care control group. The intervention included online education, self-monitoring and prompt tools (wearable devices, smartphone apps, computer apps) and health coaching. Feasibility outcomes were recruitment, attrition, data completion rates and intervention acceptability. Measurements of device-assessed sitting (intended primary outcome for definitive trial), standing and stepping, and physical function, psychosocial health and wellbeing were taken at baseline, 3 months and 6 months. Individual semi-structured interviews were conducted at six-months (post intervention) to explore acceptability, feasibility and experiences of the trial and intervention using the Framework Method.

RESULTS

Seventy participants aged 55 ± 11 years were recruited. Recruitment rate (proportion of eligible participants enrolled into the study) was 67% and participant retention rate at 6 months was 93% (n = 5 withdrawals). Data completion rates for daily sitting were 100% at baseline and ranged from 83 to 91% at 3 months and 6 months. Descriptive analysis demonstrated potential for the intervention to reduce device-measured sitting, which was 30.9 ± 87.2 and 22.2 ± 82.5 min/day lower in the intervention group at 3 and 6 months, respectively, compared with baseline. In the control group, sitting was 4.4 ± 99.5 and 23.7 ± 85.2 min/day lower at 3 and 6 months, respectively. Qualitative analysis identified three themes: reasons for participating in the trial, acceptability of study procedures, and the delivery and experience of taking part in the RESIT intervention. Overall, the measurement visits and intervention were acceptable to participants.

CONCLUSIONS

This study demonstrated the feasibility and acceptability of the RESIT intervention and evaluation methods, supporting a future definitive trial. If RESIT is found to be clinically effective, this could lead to changes in diabetes healthcare with a focus on reducing sitting.

TRIAL REGISTRATION

The trial was registered with ISRCTN (number ISRCTN14832389).

Applications of digital health approaches for cardiometabolic diseases prevention and management in the Western Pacific region

Cardiometabolic diseases (CMDs) are the major types of non-communicable diseases, contributing to huge disease burdens in the Western Pacific region (WPR). The use of digital health (dHealth) technologies, such as wearable gadgets, mobile apps, and artificial intelligence (AI), facilitates interventions for CMDs prevention and treatment. Currently, most studies on dHealth and CMDs in WPR were conducted in a few high- and middle-income countries like Australia, China, Japan, the Republic of Korea, and New Zealand. Evidence indicated that dHealth services promoted early prevention by behavior interventions, and AI-based innovation brought automated diagnosis and clinical decision-support. dHealth brought facilitators for the doctor-patient interplay in the effectiveness, experience, and communication skills during healthcare services, with rapidly development during the pandemic of coronavirus disease 2019. In the future, the improvement of dHealth services in WPR needs to gain more policy support, enhance technology innovation and privacy protection, and perform cost-effectiveness research.

Implementation and engagement of the SMART Work & Life sitting reduction intervention: an exploratory analysis on intervention effectiveness

BACKGROUND

To enhance the impact of interventions, it is important to understand how intervention engagement relates to study outcomes. We report on the level of implementation and engagement with the SMART Work & Life (SWAL) programme (delivered with (SWAL plus desk) and without a height-adjustable desk (SWAL)) and explore the effects of different levels of this on change in daily sitting time in comparison to the control group.

METHODS

The extent of intervention delivery by workplace champions and the extent of engagement by champions and participants (staff) with each intervention activity was assessed by training attendance logs, workplace champion withdrawal dates, intervention activities logs and questionnaires. These data were used to assess whether a cluster met defined criteria for low, medium, or high implementation and engagement or none of these. Mixed effects linear regression analyses tested whether change in sitting time varied by: (i) the number of intervention activities implemented and engaged with, and (ii) the percentage of implementation and engagement with all intervention strategies.

RESULTS

Workplace champions were recruited for all clusters, with 51/52 (98%) attending training. Overall, 12/27 (44.4%) SWAL and 9/25 (36.0%) SWAL plus desk clusters implemented all main intervention strategies. Across remaining clusters, the level of intervention implementation varied. Those in the SWAL (n = 8 (29.6%) clusters, 80 (32.1%) participants) and SWAL plus desk (n = 5 (20.0%) clusters, 41 (17.1%) participants) intervention groups who implemented and engaged with the most intervention strategies and had the highest percentage of cluster implementation and engagement with all intervention strategies sat for 30.9 (95% CI -53.9 to -7.9, p = 0.01) and 75.6 (95% CI -103.6 to -47.7, p < 0.001) fewer minutes/day respectively compared to the control group at 12 month follow up. These differences were larger than the complete case analysis. The differences in sitting time observed for the medium and low levels were similar to the complete case analysis.

CONCLUSIONS

Most intervention strategies were delivered to some extent across the clusters although there was large variation. Superior effects for sitting reduction were seen for those intervention groups who implemented and engaged with the most intervention components and had the highest level of cluster implementation and engagement.

TRIAL REGISTRATION

ISRCTN11618007. Registered on 24 January 2018. https://www.isrctn.com/ISRCTNISRCTN11618007 .

Internet use, exposure to digital family planning messages, and sexual agency among partnered women in Northern Nigeria: implications for digital family planning intervention

Digital health interventions are gaining ground in conflict-affected countries, but studies on their reproductive health benefits for women are scanty. Focusing on conflict-affected northern Nigeria, this study examined the relationships between Internet use, exposure to digital family planning messages via text messages or social media, and sexual agency - measured as the ability to refuse sex and ask a male partner to use a condom - among partnered women including the rural-urban differentials. Partnered women's data (n= 18,205) from the 2018 Nigeria Demographic and Health Survey were analysed using descriptive and multinomial logistic regression analyses. 44.6% of women are able to refuse sex, and 31.4% to ask a male partner to use a condom. Internet use was positively associated with women's ability to refuse sex in the northern region and urban areas, and across the region to ask a male partner to use a condom. It was also positively associated with women's uncertainty about asking a male partner to use a condom. Exposure to digital family planning messages was positively associated with women's ability to ask a male partner to use a condom across the region, in both urban and rural areas. However, exposure to digital family planning messages was negatively associated with women's uncertainty in urban areas about their ability to refuse sex. Implications of these findings for digital family planning interventions are discussed.

The Feasibility of a Text-Messaging Intervention Promoting Physical Activity in Shift Workers: A Process Evaluation

Workplace health promotion programs (WHPPs) can improve shift workers' physical activity. The purpose of this paper is to present the process evaluation of a text messaging health promotion intervention for mining shift workers during a 24-day shift cycle. Data collected from intervention participants with a logbook (n = 25) throughout the intervention, exit interviews (n = 7) and online surveys (n = 17) examined the WHPP using the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) framework. The program reached 66% of workers across three departments, with 15% of participants dropping out. The program showed the potential to be adopted if the recruitment strategies are improved to reach more employees, especially when involving work managers for recruitment. A few changes were made to the program, and participant adherence was high. Facilitators to adopt and implement the health promotion program included the use of text messaging to improve physical activity, feedback on behaviour, and providing incentives. Work-related fatigue was reported as a barrier to implementing the program. Participants reported that they would recommend the program to other workers and use the Mi fitness band to continue monitoring and improving their health behaviour. This study showed that shift workers were optimistic about health promotion. Allowing for long-term evaluation and involving the company management to determine scale-up should be considered for future programs.

Preliminary Efficacy, Feasibility, and Perceived Usefulness of a Smartphone-Based Self-Management System with Personalized Goal Setting and Feedback to Increase Step Count among Workers with High Blood Pressure: Before-After Study (Preprint)

BACKGROUND

High blood pressure (BP) and physical inactivity are the major risk factors for cardiovascular diseases. Mobile health is expected to support patients' self-management for improving cardiovascular health; the development of fully automated systems is necessary to minimize the workloads of health care providers.

OBJECTIVE

The objective of our study was to evaluate the preliminary efficacy, feasibility, and perceived usefulness of an intervention using a novel smartphone-based self-management system (DialBetes Step) in increasing steps per day among workers with high BP.

METHODS

On the basis of the Social Cognitive Theory, we developed personalized goal-setting and feedback functions and information delivery functions for increasing step count. Personalized goal setting and feedback consist of 4 components to support users' self-regulation and enhance their self-efficacy: goal setting for daily steps, positive feedback, action planning, and barrier identification and problem-solving. In the goal-setting component, users set their own step goals weekly in gradual increments based on the system's suggestion. We added these fully automated functions to an extant system with the function of self-monitoring daily step count, BP, body weight, blood glucose, exercise, and diet. We conducted a single-arm before-and-after study of workers with high BP who were willing to increase their physical activity. After an educational group session, participants used only the self-monitoring function for 2 weeks (baseline) and all functions of DialBetes Step for 24 weeks. We evaluated changes in steps per day, self-reported frequencies of self-regulation and self-management behavior, self-efficacy, and biomedical characteristics (home BP, BMI, visceral fat area, and glucose and lipid parameters) around week 6 (P1) of using the new functions and at the end of the intervention (P2). Participants rated the usefulness of the system using a paper-based questionnaire.

RESULTS

We analyzed 30 participants (n=19, 63% male; mean age 52.9, SD 5.3 years); 1 (3%) participant dropped out of the intervention. The median percentage of step measurement was 97%. Compared with baseline (median 10,084 steps per day), steps per day significantly increased at P1 (median +1493 steps per day; P<.001), but the increase attenuated at P2 (median +1056 steps per day; P=.04). Frequencies of self-regulation and self-management behavior increased at P1 and P2. Goal-related self-efficacy tended to increase at P2 (median +5%; P=.05). Home BP substantially decreased only at P2. Of the other biomedical characteristics, BMI decreased significantly at P1 (P<.001) and P2 (P=.001), and high-density lipoprotein cholesterol increased significantly only at P1 (P<.001). DialBetes Step was rated as useful or moderately useful by 97% (28/29) of the participants.

CONCLUSIONS

DialBetes Step intervention might be a feasible and useful way of increasing workers' step count for a short period and, consequently, improving their BP and BMI; self-efficacy-enhancing techniques of the system should be improved.

Impact of COVID-19 Pandemic on Research Participation Among Older African Americans

COVID-19 represents the newest health disparity faced by African Americans (AA). This study assessed the impact of COVID-19 on barriers and willingness to participate in research among older AAs. An online survey was sent to a nationwide sample of 65- to 85-year-old AAs between January and February 2021. Constant comparison analysis was used to extract themes. A total of 624 older AAs completed the survey. Approximately 40% of participants were willing to engage in virtual or in-person research. Of the individuals who were willing to participate in research, >50% were willing to engage in a spectrum of activities from group discussions to group exercise. Research participation themes related to logistics, technology, pandemic fears, and privacy or security. Older AAs face new research barriers that can be overcome through data use transparency and technology resources. This information can be used to encourage dementia research engagement among older AAs despite the pandemic.

Development of a Novel Intervention (Mindful Steps) to Promote Long-Term Walking Behavior in Chronic Cardiopulmonary Disease: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite current rehabilitation programs, long-term engagement in physical activity remains a significant challenge for patients with chronic obstructive pulmonary disease (COPD) and heart failure (HF). Novel strategies to promote physical activity in these populations are greatly needed. Emerging literature on the benefits of both mind-body interventions and web-based interventions provide the rationale for the development of the Mindful Steps intervention for increasing walking behavior.

OBJECTIVE

This study aims to develop a novel multimodal mind-body exercise intervention through adaptation of an existing web-based physical activity intervention and incorporation of mind-body exercise, and to pilot test the delivery of the new intervention, Mindful Steps, in a randomized controlled feasibility trial in older adults with COPD and/or HF.

METHODS

In phase 1, guided by a theoretical conceptual model and review of the literature on facilitators and barriers of physical activity in COPD and HF, we convened an expert panel of researchers, mind-body practitioners, and clinicians to inform development of the novel, multimodal intervention. In phase 2, we are conducting a pilot randomized controlled feasibility trial of the Mindful Steps intervention that includes in-person mind-body exercise classes, an educational website, online mind-body videos, and a pedometer with step-count feedback and goals to increase walking behavior in patients with COPD and/or HF. Outcomes include feasibility measures as well as patient-centered measures.

RESULTS

The study is currently ongoing. Phase 1 intervention development was completed in March 2019, and phase 2 data collection began in April 2019.

CONCLUSIONS

Through the integration of components from a web-based physical activity intervention and mind-body exercise, we created a novel, multimodal program to impact long-term physical activity engagement for individuals with COPD and HF. This developmental work and pilot study will provide valuable information needed to design a future clinical trial assessing efficacy of this multimodal approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03003780; https://clinicaltrials.gov/ct2/show/NCT03003780.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27826.

Associations Between Digital Health Intervention Engagement, Physical Activity, and Sedentary Behavior: Systematic Review and Meta-analysis

BACKGROUND

The effectiveness of digital health interventions is commonly assumed to be related to the level of user engagement with the digital health intervention, including measures of both digital health intervention use and users' subjective experience. However, little is known about the relationships between the measures of digital health intervention engagement and physical activity or sedentary behavior.

OBJECTIVE

This study aims to describe the direction and strength of the association between engagement with digital health interventions and physical activity or sedentary behavior in adults and explore whether the direction of association of digital health intervention engagement with physical activity or sedentary behavior varies with the type of engagement with the digital health intervention (ie, subjective experience, activities completed, time, and logins).

METHODS

Four databases were searched from inception to December 2019. Grey literature and reference lists of key systematic reviews and journals were also searched. Studies were eligible for inclusion if they examined a quantitative association between a measure of engagement with a digital health intervention targeting physical activity and a measure of physical activity or sedentary behavior in adults (aged ≥18 years). Studies that purposely sampled or recruited individuals on the basis of pre-existing health-related conditions were excluded. In addition, studies were excluded if the individual engaging with the digital health intervention was not the target of the physical activity intervention, the study had a non-digital health intervention component, or the digital health interventions targeted multiple health behaviors. A random effects meta-analysis and direction of association vote counting (for studies not included in meta-analysis) were used to address objective 1. Objective 2 used vote counting on the direction of the association.

RESULTS

Overall, 10,653 unique citations were identified and 375 full texts were reviewed. Of these, 19 studies (26 associations) were included in the review, with no studies reporting a measure of sedentary behavior. A meta-analysis of 11 studies indicated a small statistically significant positive association between digital health engagement (based on all usage measures) and physical activity (0.08, 95% CI 0.01-0.14, SD 0.11). Heterogeneity was high, with 77% of the variation in the point estimates explained by the between-study heterogeneity. Vote counting indicated that the relationship between physical activity and digital health intervention engagement was consistently positive for three measures: subjective experience measures (2 of 3 associations), activities completed (5 of 8 associations), and logins (6 of 10 associations). However, the direction of associations between physical activity and time-based measures of usage (time spent using the intervention) were mixed (2 of 5 associations supported the hypothesis, 2 were inconclusive, and 1 rejected the hypothesis).

CONCLUSIONS

The findings indicate a weak but consistent positive association between engagement with a physical activity digital health intervention and physical activity outcomes. No studies have targeted sedentary behavior outcomes. The findings were consistent across most constructs of engagement; however, the associations were weak.

A Technology-Mediated Interventional Approach to the Prevention of Metabolic Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND

Technology-mediated interventions help overcome barriers to program delivery and spread metabolic syndrome prevention programs on a large scale. A meta-analysis was performed to evaluate the impact of these technology-mediated interventions on metabolic syndrome prevention.

METHODS

In this meta-analysis, from 30 January 2018, three databases were searched to evaluate interventions using techniques to propagate diet and exercise lifestyle programs for adult patients with metabolic syndrome or metabolic risk.

RESULTS

Search results found 535 citations. Of these, 18 studies met the inclusion criteria analyzed in this article. The median duration of intervention was 4 months and the follow-up period ranged from 1.5 to 30 months. The standardized mean difference (SMD) between the two groups was waist circumference -0.35 (95% CI -0.54, -0.15), triglyceride -0.14 (95% CI -0.26, -0.03), fasting blood glucose -0.31 (95% CI -0.42, -0.19), body weight -1.34 (95% CI -2.04, -0.64), and body mass index -1.36 (95% CI -2.21, -0.51). There was no publication bias in this study.

CONCLUSION

Technology-mediated intervention improved clinically important metabolic syndrome related indicators such as excess body fat around the waist, fasting glucose, and body mass index. These interventions will play an important role in the dissemination of metabolic syndrome prevention programs.

Mental health benefits from lifestyle physical activity interventions: A systematic review

Lifestyle physical activity (LPA) interventions are a promising alternative to structured exercise interventions for addressing mental health problems. The authors conducted a systematic review of the literature on LPA interventions in any population in order to determine (a) the extent to which mental health outcomes were examined and (b) whether benefits in mental health outcomes were observed. Mental health outcomes were defined as depression, anxiety, perceived stress, health-related quality of life, and psychological well-being. A total of 73 articles were identified as LPA intervention, of which 24.7% (n = 18) reported the effect of LPA intervention on mental health outcomes. The most commonly evaluated mental health outcome was depression, and to a lesser extent anxiety and perceived stress. Overall, findings point to promising effects of LPA interventions across common mental health problems. Key areas for future research are discussed in light of emergent limitations in existing published studies.

Can physical activity measurement alone improve objectively-measured physical activity in primary care?: A systematic review and meta-analysis

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Some evidence of control group increases in self-reported PA in primary care.

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Meta-analyses found no significant improvement in control group objectively-measured PA.

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17% of studies reported increased (≥10%) objectively-measured PA in control groups.

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Healthy younger adults may increase objectively-measured PA with measurement alone.

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PA measurement using pedometers alone may be particularly useful to increase PA.

There is evidence that simply measuring physical activity alone can increase self-reported physical activity behaviour. The aim of this review was to describe changes in objectively-measured physical activity within control groups in primary care physical activity intervention studies. Five electronic databases (PubMed, MEDLINE, SPORTDiscus, PsychINFO and CINAHL) were searched from inception to February 2019. Physical activity controlled intervention studies objectively measuring physical activity in primary care with adults were included and meta-analyses were completed. Thirty studies were eligible and 22 studies were included in the meta-analysis. No statistically significant change in steps.day⁻¹, counts.day⁻¹ and counts.minute^-1 were found in the meta-analyses within control groups. Moderate-to-vigorous physical activity minutes.day⁻¹ significantly decreased (-3.97; 95% CI −6.31 to −1.64; P < 0.001). Sub-analyses revealed there was a trend for steps.day⁻¹ to increase in participants < 50 years old (504; 95% CI −20 to 1029; P = 0.06). Noteworthy increases (≥10%) in objectively-measured physical activity within control groups were found in 17% of studies. Noteworthy increases were reported in studies with younger participants, one-third of the pedometer studies, one-third of studies with participants at risk of chronic disease and in studies with a shorter duration between measurements. No control group improvements were found in participants with chronic disease. Overall, no significant improvements in objectively-measured physical activity were found within control groups in primary care. Further investigation of noteworthy increases in control group physical activity levels is indicated, particularly in certain sub-groups of participants as this may effect physical activity research and interventions in these populations.

Neighborhood Environment Characteristics and Control of Hypertension and Diabetes in a Primary Care Patient Sample

BACKGROUND

Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care.

OBJECTIVE

To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control.

DESIGN

Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017.

PARTICIPANTS

Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010-2011.

MAIN MEASURES

Census tract-level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. Diabetes control defined as HgbA1c < 7.

KEY RESULTS

Among patients with hypertension, neighborhood conditions were not associated with lower odds of blood pressure control after accounting for patient and physician characteristics. However, among patients with diabetes, in fully adjusted models accounting for patient and physician characteristics, we found that patients residing in neighborhoods with low and moderate SES had reduced odds of diabetes control (OR = 0.74 (95% CI = 0.57-0.97) and OR = 0.75 (95% CI = 0.57-0.98), respectively) compared to those living in high-SES neighborhoods.

CONCLUSIONS

Neighborhood disadvantage may contribute to poor diabetes control among patients in clinical care. Community-based chronic disease care management strategies to improve diabetes control may be optimally effective if they also address neighborhood SES among patients engaged in care.

Smartphone Cardiac Rehabilitation, Assisted Self-Management Versus Usual Care: Protocol for a Multicenter Randomized Controlled Trial to Compare Effects and Costs Among People With Coronary Heart Disease

Background

Alternative evidence-based cardiac rehabilitation (CR) delivery models that overcome significant barriers to access and delivery are needed to address persistent low utilization. Models utilizing contemporary digital technologies could significantly improve reach and fidelity as complementary alternatives to traditional center-based programs.

Objective

The aim of this study is to compare the effects and costs of the innovative Smartphone Cardiac Rehabilitation, Assisted self-Management (SCRAM) intervention with usual care CR.

Methods

In this investigator-, assessor-, and statistician-blinded parallel 2-arm randomized controlled trial, 220 adults (18+ years) with coronary heart disease are being recruited from 3 hospitals in metropolitan and regional Victoria, Australia. Participants are randomized (1:1) to receive advice to engage with usual care CR or the SCRAM intervention. SCRAM is a 24-week dual-phase intervention that includes 12 weeks of real-time remote exercise supervision and coaching from exercise physiologists, which is followed by 12 weeks of data-driven nonreal-time remote coaching via telephone. Both intervention phases include evidence- and theory-based multifactorial behavior change support delivered via smartphone push notifications. Outcomes assessed at baseline, 12 weeks, and 24 weeks include maximal aerobic exercise capacity (primary outcome at 24 weeks), modifiable cardiovascular risk factors, exercise adherence, secondary prevention self-management behaviors, health-related quality of life, and adverse events. Economic and process evaluations will determine cost-effectiveness and participant perceptions of the treatment arms, respectively.

Results

The trial was funded in November 2017 and received ethical approval in June 2018. Recruitment began in November 2018. As of September 2019, 54 participants have been randomized into the trial.

Conclusions

The innovative multiphase SCRAM intervention delivers real-time remote exercise supervision and evidence-based self-management behavioral support to participants, regardless of their geographic proximity to traditional center-based CR facilities. Our trial will provide unique and valuable information about effects of SCRAM on outcomes associated with cardiac and all-cause mortality, as well as acceptability and cost-effectiveness. These findings will be important to inform health care providers about the potential for innovative program delivery models, such as SCRAM, to be implemented at scale, as a complement to existing CR programs. The inclusion of a cohort comprising metropolitan-, regional-, and rural-dwelling participants will help to understand the role of this delivery model across health care contexts with diverse needs.

Trial Registration

Australian New Zealand Clinical Trials Registry (ACTRN): 12618001458224; anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374508.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15022

Effectiveness Studies in Health Promotion: A Review of the Methodological Quality of Studies Reporting Significant Effects on Physical Activity in Working Age Adults

The methodology of intervention studies on physical activity (PA) promotion is of great importance regarding evidence development in complex interventions. The aim of this review was to provide an overview of the methodological quality of those studies which reported statistically significant effects of interventions promoting PA. PUBMED was searched for reviews on PA promotion to identify studies reporting effective interventions with participants of working age (16⁻67 years). Selected reviews were screened and data from primary studies with effective interventions were extracted to assess methodological quality. Forty-six reviews with 600 primary studies were identified, of which 33 met the inclusion criteria. Twenty-one studies were conducted as randomized controlled trials, 13 included an intervention control group, 25 measured PA by questionnaire, and 13 included objective measurements. Information on used statistics was often scarce, and long-term follow-up measurements were frequently missing. The overall methodological quality was moderate for randomized studies and low for non-randomized studies; information on methods and results was often lacking. To overcome these methodological issues, standardized guidelines for reporting study results should be considered, not only when publishing results but also when designing studies. This review provides a solid foundation for the development of practical advice for planning application-oriented studies in PA promotion.

Gamifying Accelerometer Use Increases Physical Activity Levels of Sedentary Office Workers

Background

Sedentary work is hazardous. Over 80% of all US jobs are predominantly sedentary, placing full‐time office workers at increased risk for cardiovascular and metabolic morbidity and mortality. Thus, there is a critical need for effective workplace physical activity interventions. MapTrek is a mobile health platform that gamifies Fitbit use for the purpose of promoting physical activity. The purpose of this study was to test the efficacy of MapTrek for increasing daily steps and moderate‐intensity steps over 10 weeks in a sample of sedentary office workers.

Methods and Results

Participants included 146 full‐time sedentary office workers aged 21 to 65 who reported sitting at least 75% of their workday. Each participant received a Fitbit Zip to wear daily throughout the intervention. Participants were randomized to either a: (1) Fitbit‐only group or 2) Fitbit + MapTrek group. Physical activity outcomes and intervention compliance were measured with the Fitbit activity monitor. The Fitbit + MapTrek group significantly increased daily steps (+2092 steps per day) and active minutes (+11.2 min/day) compared to the Fitbit‐only arm, but, on average, participants’ steps declined during the study period.

Conclusions

MapTrek is an effective approach for increasing physical activity at a clinically meaningful level in sedentary office workers, but as with accelerometer use alone, the effect decreases over time.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03109535.

A Self-Regulation-Based eHealth Intervention to Promote a Healthy Lifestyle: Investigating User and Website Characteristics Related to Attrition

BACKGROUND

eHealth interventions can reach large populations and are effective in increasing physical activity (PA) and fruit and vegetable intake. Nevertheless, the effects of eHealth interventions are overshadowed by high attrition rates. Examining more closely when users decide to leave the intervention can help eHealth developers to make informed decisions about which intervention components should be reshaped or simply removed. Investigating which users are more likely to quit an intervention can inform developers about whether and how their intervention should be adapted to specific subgroups of users.

OBJECTIVE

This study investigated the pattern of attrition in a Web-based intervention to increase PA, fruit, and vegetable intake. The first aim was to describe attrition rates according to different self-regulation components. A second aim was to investigate whether certain user characteristics are predictors for start session completion, returning to a follow-up session and intervention completion.

METHODS

The sample consisted of 549 adults who participated in an online intervention, based on self-regulation theory, to promote PA and fruit and vegetable intake, called "MyPlan 1.0." Using descriptive analysis, attrition was explored per self-regulation component (eg, action planning and coping planning). To identify which user characteristics predict completion, logistic regression analyses were conducted.

RESULTS

At the end of the intervention program, there was an attrition rate of 78.2% (330/422). Attrition rates were very similar for the different self-regulation components. However, attrition levels were higher for the fulfillment of questionnaires (eg, to generate tailored feedback) than for the more interactive components. The highest amount of attrition could be observed when people were asked to make their own action plan. There were no significant predictors for first session completion. Yet, two subgroups had a lower chance to complete the intervention, namely male users (OR: 2.24, 95% CI=1.23-4.08) and younger adults (OR: 1.02, 95% CI=1.00-1.04). Furthermore, younger adults were less likely to return to the website for the first follow-up after one week (OR: 1.03, 95% CI=1.01-1.04).

CONCLUSIONS

This study informs us that eHealth interventions should avoid the use of extensive questionnaires and that users should be provided with a rationale for several components (eg, making an action plan and completing questions). Furthermore, future interventions should focus first on motivating users for the behavior change before guiding them through action planning. Though, this study provides no evidence for removal of one of the self-regulation techniques based on attrition rates. Finally, strong efforts are needed to motivate male users and younger adults to complete eHealth interventions.

Strategies for Worksite Health Interventions to Employees with Elevated Risk of Chronic Diseases

Chronic disease rates have become more prevalent in the modern American workforce, which has negative implications for workplace productivity and healthcare costs. Offering workplace health interventions is recognized as an effective strategy to reduce chronic disease progression, absenteeism, and healthcare costs as well as improve population health. This review documents intervention and evaluation strategies used for health promotion programs delivered in workplaces. Using predetermined search terms in five online databases, we identified 1,131 published items from 1995 to 2014. Of these items, 27 peer-reviewed articles met the inclusion criteria; reporting data from completed United States-based workplace interventions that recruited at-risk employees based on their disease or disease-related risk factors. A content rubric was developed and used to catalogue these 27 published field studies. Selected workplace interventions targeted obesity (n = 13), cardiovascular diseases (n = 8), and diabetes (n = 6). Intervention strategies included instructional education/counseling (n = 20), workplace environmental change (n = 6), physical activity (n = 10), use of technology (n = 10), and incentives (n = 13). Self-reported data (n = 21), anthropometric measurements (n = 17), and laboratory tests (n = 14) were used most often in studies with outcome evaluation. This is the first literature review to focus on interventions for employees with elevated risk for chronic diseases. The review has the potential to inform future workplace health interventions by presenting strategies related to implementation and evaluation strategies in workplace settings. These strategies can help determine optimal worksite health programs based on the unique characteristics of work settings and the health risk factors of their employee populations.

Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses

PURPOSE

This systematic review aims to explain the heterogeneity in results of interventions to promote physical activity and healthy eating for overweight and obese adults, by exploring the differential effects of behaviour change techniques (BCTs) and other intervention characteristics.

METHODS

The inclusion criteria specified RCTs with ≥ 12 weeks' duration, from January 2007 to October 2014, for adults (mean age ≥ 40 years, mean BMI ≥ 30). Primary outcomes were measures of healthy diet or physical activity. Two reviewers rated study quality, coded the BCTs, and collected outcome results at short (≤6 months) and long term (≥12 months). Meta-analyses and meta-regressions were used to estimate effect sizes (ES), heterogeneity indices (I²) and regression coefficients.

RESULTS

We included 48 studies containing a total of 82 outcome reports. The 32 long term reports had an overall ES = 0.24 with 95% confidence interval (CI): 0.15 to 0.33 and I² = 59.4%. The 50 short term reports had an ES = 0.37 with 95% CI: 0.26 to 0.48, and I² = 71.3%. The number of BCTs unique to the intervention group, and the BCTs goal setting and self-monitoring of behaviour predicted the effect at short and long term. The total number of BCTs in both intervention arms and using the BCTs goal setting of outcome, feedback on outcome of behaviour, implementing graded tasks, and adding objects to the environment, e.g. using a step counter, significantly predicted the effect at long term. Setting a goal for change; and the presence of reporting bias independently explained 58.8% of inter-study variation at short term. Autonomy supportive and person-centred methods as in Motivational Interviewing, the BCTs goal setting of behaviour, and receiving feedback on the outcome of behaviour, explained all of the between study variations in effects at long term.

CONCLUSION

There are similarities, but also differences in effective BCTs promoting change in healthy eating and physical activity and BCTs supporting maintenance of change. The results support the use of goal setting and self-monitoring of behaviour when counselling overweight and obese adults. Several other BCTs as well as the use of a person-centred and autonomy supportive counselling approach seem important in order to maintain behaviour over time.

TRIAL REGISTRATION

PROSPERO CRD42015020624.

Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses

Purpose

This systematic review aims to explain the heterogeneity in results of interventions to promote physical activity and healthy eating for overweight and obese adults, by exploring the differential effects of behaviour change techniques (BCTs) and other intervention characteristics.

Methods

The inclusion criteria specified RCTs with ≥ 12 weeks’ duration, from January 2007 to October 2014, for adults (mean age ≥ 40 years, mean BMI ≥ 30). Primary outcomes were measures of healthy diet or physical activity. Two reviewers rated study quality, coded the BCTs, and collected outcome results at short (≤6 months) and long term (≥12 months). Meta-analyses and meta-regressions were used to estimate effect sizes (ES), heterogeneity indices (I²) and regression coefficients.

Results

We included 48 studies containing a total of 82 outcome reports. The 32 long term reports had an overall ES = 0.24 with 95% confidence interval (CI): 0.15 to 0.33 and I² = 59.4%. The 50 short term reports had an ES = 0.37 with 95% CI: 0.26 to 0.48, and I² = 71.3%. The number of BCTs unique to the intervention group, and the BCTs goal setting and self-monitoring of behaviour predicted the effect at short and long term. The total number of BCTs in both intervention arms and using the BCTs goal setting of outcome, feedback on outcome of behaviour, implementing graded tasks, and adding objects to the environment, e.g. using a step counter, significantly predicted the effect at long term. Setting a goal for change; and the presence of reporting bias independently explained 58.8% of inter-study variation at short term. Autonomy supportive and person-centred methods as in Motivational Interviewing, the BCTs goal setting of behaviour, and receiving feedback on the outcome of behaviour, explained all of the between study variations in effects at long term.

Conclusion

There are similarities, but also differences in effective BCTs promoting change in healthy eating and physical activity and BCTs supporting maintenance of change. The results support the use of goal setting and self-monitoring of behaviour when counselling overweight and obese adults. Several other BCTs as well as the use of a person-centred and autonomy supportive counselling approach seem important in order to maintain behaviour over time.

Trial Registration

PROSPERO CRD42015020624

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0494-y) contains supplementary material, which is available to authorized users.

Applying Psychological Theories to Promote Long-Term Maintenance of Health Behaviors

Behavioral health theory provides a framework for researchers to design, implement, and evaluate the effects of health promotion programs. However, limited research has examined theories used in interventions to promote long-term maintenance of health behaviors. The purpose of this review was to evaluate the available literature and identify prominent behavioral health theories used in intervention research to promote maintenance of health behaviors. We reviewed theories used in intervention research assessing long-term maintenance (≥ 6 months post-intervention) of physical activity, weight loss, and smoking cessation. Five prominent behavioral theories were referenced by the 34 studies included in the review: Self-Determination Theory, Theory of Planned Behavior, Social Cognitive Theory, Transtheoretical Model, and Social Ecological Model. Descriptions and examples of applications of these theories are provided. Implications for future research are discussed.

Self-directed interventions to promote weight loss: a systematic review and meta-analysis

Many self-directed weight-loss interventions have been developed using a variety of delivery formats (e.g., internet and smartphone) and change techniques. Yet, little research has examined whether self-directed interventions can exclusively promote weight loss. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library were systematically reviewed for randomised controlled trials evaluating self-directed interventions in relation to weight-loss outcomes in adults. Standardised mean differences (SMD) and 95% confidence intervals (CI) were calculated using a random effects model. Twenty-seven trials incorporating 36 comparisons met our inclusion criteria. Participants using self-directed interventions lost significantly more weight (MD = -1.56 kg, CI -2.25, -0.86 ranging from 0.6 to 5.3 kg) compared to those in the minimal intervention or no-treatment groups (3.1-month follow-up median). The majority of interventions were internet based (18 evaluations) and these were effective at 3 months (MD = -1.74 kg, CI -2.65, -0.82 ranging from 0.6 to 4.8 kg) (SMD = -0.48, 95% CI -0.72, -0.24, I(2) = 82%; p < .0001; 16 evaluations) and 6 months follow-up (MD = -2.71 kg, CI -4.03, -1.39 ranging from 2.2 to 5.3 kg) (SMD = -0.59, 95% CI -0.99, -0.19, I(2) = 76%; p = .004; 4 evaluations). Self-directed weight-loss interventions can generate modest weight loss for up to 6 months but may need to be supplemented by other interventions to achieve sustained and clinically meaningful weight loss.

A Web-Based Intervention to Encourage Walking (StepWise): Pilot Randomized Controlled Trial

Background

Despite Internet-based interventions that incorporate pedometers with appropriate goal-setting processes and other theoretically-based behavior change strategies being proposed as a means of increasing walking behavior, few have incorporated all of these key features or assessed maintenance of behavior change.

Objective

The objective of our study was to investigate the effect of a 12-week pedometer step goal walking program individually tailored to baseline step counts, combined with an interactive support website for step counts, health parameters and motivation over 12 and 24 weeks.

Methods

Low active participants (mean [SD] 46.2 [11.2] years) were randomly assigned to the Stepwise (SW) intervention group (n=49) or a comparison (CP) group (n=48). SW received a pedometer, step goal walking program and access to the SW website (containing interactive self-monitoring and goal feedback tools, motivational messages and action and coping planning strategies). CP received a pedometer and locally available physical activity information. Step counts, BMI, resting heart rate, blood pressure and glucose, cholesterol and triglyceride levels, psychological well-being, perceived health, self-efficacy and self-determined motivation were measured at baseline, 12 and 24 weeks.

Results

Linear mixed model analysis found that both groups’ step counts increased from baseline to week 12 (β = 11,002, CI 5739-16,266, P<.001) and 24 (β = 6810, CI 1190-12,431; P=.02). Group step counts were significantly different at week 24 with SW taking 8939 (CI 274-17604, P=.04) more steps compared to CP. Compared to baseline, both groups had improved triglyceride levels (0.14 mmol/L, CI -0.25 to -0.02, P=.02) at week 12, decreased diastolic blood pressure (4.22 mmHg, CI -6.73 to -1.72) at weeks 12 and 24 (3.17 mmHg, CI -5.55 to -0.78), improved positive (β = .21, CI 0.03-0.38, P=.02) and negative affect (β = -.15, CI -0.28 to -0.03, P=.02) at week 12, and perceived health at week 12 (β = 6.37, CI 2.10-10.65, P=.004) and 24 (β = 8.52, CI 3.98-13.06, P<.001). Total cholesterol increased at week 12 (0.26 mmol/L, CI 0.099-0.423, P=.006) and week 24 (0.38 mmol/L, CI 0.20-0.56, P<.001). Repeated measures ANOVA found motivation for walking improved from baseline with higher task self-efficacy (P<.001, η² = .13) and autonomous motivation (P<.001, η²=.14) at weeks 12 and 24 and decreased controlled motivation (P=.004, η²=.08) at week 24.

Conclusions

Both groups had similar improvements in step counts and physical and psychological health after 12 weeks but only the SW group successfully maintained the increased step-counts 24 weeks post-intervention. This suggests the step-goal based walking program combined with Internet-based behavior change tools were important for sustained behavior change.

Systematic Review of Physical Activity Outcomes of Rural Lifestyle Interventions

The purpose of this systematic review is to analyze current lifestyle intervention literature conducted in U.S. rural areas to identify the most effective and impactful interventions on physical activity outcomes. Quality of studies was assessed using the Cochrane Collaboration's risk of bias tool. Exploratory calculations of effect size and 95% confidence intervals were performed to demonstrate trends in clinical importance. Eight trials which included 1,399 adult participants met the inclusion criteria for review. Two trials reported a significant difference in the increase of physical activity between groups with medium to large effect sizes. Interventions which are very personalized or tailored and/or include many intervention contacts appear to be most effective. However, the small number of studies, mixed findings, and the risk of bias limit our ability to draw conclusion.

An internet-based self-administered intervention for promoting healthy habits and weight loss in hypertensive people who are overweight or obese: a randomized controlled trial

BACKGROUND

The prevalence of overweight and obesity is on the rise worldwide with severe physical and psychosocial consequences. One of the most dangerous is hypertension. Lifestyle changes related to eating behaviour and physical activity are the critical components in the prevention and treatment of hypertension and obesity. Data indicates that the usual procedures to promote these healthy habits in health services are either insufficient or not efficient enough. Internet has been shown to be an effective tool for the implementation of lifestyle interventions based on this type of problem. This study aims to assess the efficacy of a totally self-administered online intervention programme versus the usual medical care for obese and overweight participants with hypertension (from the Spanish public health care system) to promote healthy lifestyles (eating behaviour and physical activity).

METHOD

A randomized controlled trial will be conducted with 100 patients recruited from the hypertension unit of a public hospital. Participants will be randomly assigned to one of two conditions: a) SII: a self-administered Internet-based intervention protocol; and b) MUC-medical usual care. The online intervention is an Internet-delivered, multimedia, interactive, self-administered programme, composed of nine modules designed to promote healthy eating habits and increase physical activity. The first five modules will be activated at a rate of one per week, and access for modules 5 to 9 will open every two weeks. Patients will be assessed at four points: before the intervention, after the intervention (3 months), and at 6 and 12 months (follow-up). The outcome variables will include blood pressure, and Body Mass Index, as primary outcome measures, and quality of life and other lifestyle and anthropometrical variables as secondary outcome measures.

DISCUSSION

The literature highlights the need for more studies on the benefits of using the Internet to promote lifestyle interventions. This study aims to investigate the efficiency of a totally self-administered Internet - +based programme for promoting healthy habits and improving the medical indicators of a hypertensive and overweight population.

TRIAL REGISTRATION

NCT02445833.

Evaluation of Internet-Based Interventions on Waist Circumference Reduction: A Meta-Analysis

Background

Internet-based interventions are more cost-effective than conventional interventions and can provide immediate, easy-to-access, and individually tailored support for behavior change. Waist circumference is a strong predictor of an increased risk for a host of diseases, such as hypertension, diabetes, and dyslipidemia, independent of body mass index. To date, no study has examined the effect of Internet-based lifestyle interventions on waist circumference change.

Objective

This study aimed to systematically review the effect of Internet-based interventions on waist circumference change among adults.

Methods

This meta-analysis reviewed randomized controlled trials (N=31 trials and 8442 participants) that used the Internet as a main intervention approach and reported changes in waist circumference.

Results

Internet-based interventions showed a significant reduction in waist circumference (mean change –2.99 cm, 95% CI −3.68 to −2.30, I²=93.3%) and significantly better effects on waist circumference loss (mean loss 2.38 cm, 95% CI 1.61-3.25, I²=97.2%) than minimal interventions such as information-only groups. Meta-regression results showed that baseline waist circumference, gender, and the presence of social support in the intervention were significantly associated with waist circumference reduction.

Conclusions

Internet-based interventions have a significant and promising effect on waist circumference change. Incorporating social support into an Internet-based intervention appears to be useful in reducing waist circumference. Considerable heterogeneity exists among the effects of Internet-based interventions. The design of an intervention may have a significant impact on the effectiveness of the intervention.

Effect of a Web-Based Behavior Change Program on Weight Loss and Cardiovascular Risk Factors in Overweight and Obese Adults at High Risk of Developing Cardiovascular Disease: Randomized Controlled Trial

BACKGROUND

Web-based programs are a potential medium for supporting weight loss because of their accessibility and wide reach. Research is warranted to determine the shorter- and longer-term effects of these programs in relation to weight loss and other health outcomes.

OBJECTIVE

The aim was to evaluate the effects of a Web-based component of a weight loss service (Imperative Health) in an overweight/obese population at risk of cardiovascular disease (CVD) using a randomized controlled design and a true control group.

METHODS

A total of 65 overweight/obese adults at high risk of CVD were randomly allocated to 1 of 2 groups. Group 1 (n=32) was provided with the Web-based program, which supported positive dietary and physical activity changes and assisted in managing weight. Group 2 continued with their usual self-care (n=33). Assessments were conducted face-to-face. The primary outcome was between-group change in weight at 3 months. Secondary outcomes included between-group change in anthropometric measurements, blood pressure, lipid measurements, physical activity, and energy intake at 3, 6, and 12 months. Interviews were conducted to explore participants' views of the Web-based program.

RESULTS

Retention rates for the intervention and control groups at 3 months were 78% (25/32) vs 97% (32/33), at 6 months were 66% (21/32) vs 94% (31/33), and at 12 months were 53% (17/32) vs 88% (29/33). Intention-to-treat analysis, using baseline observation carried forward imputation method, revealed that the intervention group lost more weight relative to the control group at 3 months (mean -3.41, 95% CI -4.70 to -2.13 kg vs mean -0.52, 95% CI -1.55 to 0.52 kg, P<.001), at 6 months (mean -3.47, 95% CI -4.95 to -1.98 kg vs mean -0.81, 95% CI -2.23 to 0.61 kg, P=.02), but not at 12 months (mean -2.38, 95% CI -3.48 to -0.97 kg vs mean -1.80, 95% CI -3.15 to -0.44 kg, P=.77). More intervention group participants lost ≥5% of their baseline body weight at 3 months (34%, 11/32 vs 3%, 1/33, P<.001) and 6 months (41%, 13/32 vs 18%, 6/33, P=.047), but not at 12 months (22%, 7/32 vs 21%, 7/33, P=.95) versus control group. The intervention group showed improvements in total cholesterol, triglycerides, and adopted more positive dietary and physical activity behaviors for up to 3 months verus control; however, these improvements were not sustained.

CONCLUSIONS

Although the intervention group had high attrition levels, this study provides evidence that this Web-based program can be used to initiate clinically relevant weight loss and lower CVD risk up to 3-6 months based on the proportion of intervention group participants losing ≥5% of their body weight versus control group. It also highlights a need for augmenting Web-based programs with further interventions, such as in-person support to enhance engagement and maintain these changes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01472276; http://clinicaltrials.gov/ct2/show/study/NCT01472276 (Archived by Webcite at http://www.webcitation.org/6Z9lfj8nD).

Using new technologies to promote weight management: a randomised controlled trial study protocol

Background

Over the last three decades, overweight and obesity and the associated health consequences have become global public health priorities. Methods that have been tried to address this problem have not had the desired impact, suggesting that other approaches need to be considered. One of the lessons learned throughout these attempts is that permanent weight loss requires sustained dietary and lifestyle changes, yet adherence to weight management programs has often been noted as one of the biggest challenges. This trial aims to address this issue by examining whether social media, as a potential health promotion tool, will improve adherence to a weight management program. To test the effectiveness of this measure, the designated program will be delivered via the popular social networking site Facebook, and compared to a standard delivery method that provides exactly the same content but which is communicated through a pamphlet. The trial will be conducted over a period of twelve weeks, with a twelve week follow-up. Although weight loss is expected, this study will specifically investigate the effectiveness of social media as a program delivery method. The program utilised will be one that has already been proven to achieve weight loss, namely The CSIRO Total Wellbeing Diet.

Methods/design

This project will be conducted as a 3-arm randomised controlled trial. One hundred and twenty participants will be recruited from the Perth community, and will be randomly assigned to one of the following three groups: the Facebook group, the pamphlet group, or a control group. The Facebook Group will receive the weight management program delivered via a closed group in Facebook, the Pamphlet Group will be given the same weight management program presented in a booklet, and the Control Group will follow the Australian Dietary Guidelines and the National Physical Activity Guidelines for Adults as usual care. Change in weight, body composition and waist circumference will be initial indicators of adherence to the program. Secondary outcome measures will be blood glucose, insulin, blood pressure, arterial stiffness, physical activity, eating behaviour, mental well-being (stress, anxiety, and depression), social support, self-control, self-efficacy, Facebook activity, and program evaluation.

Discussion

It is expected that this trial will support the use of social media - a source of social support and information sharing - as a delivery method for weight management programs, enhancing the reduction in weight expected from dietary and physical activity changes. Facebook is a popular, easy to access and cost-effective online platform that can be used to assist the formation of social groups, and could be translated into health promotion practice relatively easily. It is anticipated in the context of the predicted findings that social media will provide an invaluable resource for health professionals and patients alike.

Trial registration

Australian New Zealand Clinical Trials Register (ANZCTR): ACTRN12614000536662. Date registered: 21 May 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1849-4) contains supplementary material, which is available to authorized users.

Cost-effectiveness of a nurse-led internet-based vascular risk factor management programme: economic evaluation alongside a randomised controlled clinical trial

OBJECTIVE

To assess the cost-effectiveness of an internet-based, nurse-led vascular risk factor management programme in addition to usual care compared with usual care alone in patients with a clinical manifestation of a vascular disease.

DESIGN

Cost-effectiveness analysis alongside a randomised controlled trial (the Internet-based vascular Risk factor Intervention and Self-management (IRIS) study).

SETTING

Multicentre trial in a secondary and tertiary healthcare setting.

PARTICIPANTS

330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with ≥2 treatable vascular risk factors not at goal.

INTERVENTION

The intervention consisted of a personalised website with an overview and actual status of patients' vascular risk factors, and mail communication with a nurse practitioner via the website for 12 months. The intervention combined self-management support, monitoring of disease control and pharmacotherapy.

MAIN OUTCOME MEASURES

Societal costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness.

RESULTS

Patients experienced equal health benefits, that is, 0.86 vs 0.85 QALY (intervention vs usual care) at 1 year. Adjusting for baseline differences, the incremental QALY difference was -0.014 (95% CI -0.034 to 0.007). The intervention was associated with lower total costs (€4859 vs €5078, difference €219, 95% CI -€2301 to €1825). The probability that the intervention is cost-effective at a threshold value of €20,000/QALY, is 65%. At mean annual cost of €220 per patient, the intervention is relatively cheap.

CONCLUSIONS

An internet-based, nurse-led intervention in addition to usual care to improve vascular risk factors in patients with a clinical manifestation of a vascular disease does not result in a QALY gain at 1 year, but has a small effect on vascular risk factors and is associated with lower costs.

TRIAL REGISTRATION NUMBER

NCT00785031.

Development of a web-based and mobile app to support physical activity in individuals with rheumatoid arthritis: results from the second step of a co-design process

Background

Long-term adherence to physical activity recommendations remains challenging for most individuals with rheumatoid arthritis (RA) despite evidence for its health benefits.

Objective

The aim of this study was to provide basic data on system requirement specifications for a Web-based and mobile app to self-manage physical activity. More specifically, we explored the target user group, features of the future app, and correlations between the system requirements and the established behavior change techniques (BCTs).

Methods

We used a participatory action research design. Qualitative data were collected using multiple methods in four workshops. Participants were 5 individuals with RA, a clinical physiotherapist, an officer from the Swedish Rheumatism Association, a Web designer, and 2 physiotherapy researchers. A taxonomy was used to determine the degree of correlation between the system requirements and established BCTs.

Results

Participants agreed that the future Web-based and mobile app should be based on two major components important for maintaining physical activity: (1) a calendar feature for goal setting, planning, and recording of physical activity performance and progress, and (2) a small community feature for positive feedback and support from peers. All system requirements correlated with established BCTs, which were coded as 24 different BCTs.

Conclusions

To our knowledge, this study is the first to involve individuals with RA as co-designers, in collaboration with clinicians, researchers, and Web designers, to produce basic data to generate system requirement specifications for an eHealth service. The system requirements correlated to the BCTs, making specifications of content and future evaluation of effectiveness possible.

Effectiveness of a web- and mobile phone-based intervention to promote physical activity and healthy eating in middle-aged males: randomized controlled trial of the ManUp study

BACKGROUND

The high number of adult males engaging in low levels of physical activity and poor dietary practices, and the health risks posed by these behaviors, necessitate broad-reaching intervention strategies. Information technology (IT)-based (Web and mobile phone) interventions can be accessed by large numbers of people, yet there are few reported IT-based interventions targeting males' physical activity and dietary practices.

OBJECTIVE

This study examines the effectiveness of a 9-month IT-based intervention (ManUp) to improve the physical activity, dietary behaviors, and health literacy in middle-aged males compared to a print-based intervention.

METHODS

Participants, recruited offline (eg, newspaper ads), were randomized into either an IT-based or print-based intervention arm on a 2:1 basis in favor of the fully automated IT-based arm. Participants were adult males aged 35-54 years living in 2 regional cities in Queensland, Australia, who could access the Internet, owned a mobile phone, and were able to increase their activity level. The intervention, ManUp, was based on social cognitive and self-regulation theories and specifically designed to target males. Educational materials were provided and self-monitoring of physical activity and nutrition behaviors was promoted. Intervention content was the same in both intervention arms; only the delivery mode differed. Content could be accessed throughout the 9-month study period. Participants' physical activity, dietary behaviors, and health literacy were measured using online surveys at baseline, 3 months, and 9 months.

RESULTS

A total of 301 participants completed baseline assessments, 205 in the IT-based arm and 96 in the print-based arm. A total of 124 participants completed all 3 assessments. There were no significant between-group differences in physical activity and dietary behaviors (P≥.05). Participants reported an increased number of minutes and sessions of physical activity at 3 months (exp(β)=1.45, 95% CI 1.09-1.95; exp(β)=1.61, 95% CI 1.17-2.22) and 9 months (exp(β)=1.55, 95% CI 1.14-2.10; exp(β)=1.51, 95% CI 1.15-2.00). Overall dietary behaviors improved at 3 months (exp(β)=1.07, 95% CI 1.03-1.11) and 9 months (exp(β)=1.10, 95% CI 1.05-1.13). The proportion of participants in both groups eating higher-fiber bread and low-fat milk increased at 3 months (exp(β)=2.25, 95% CI 1.29-3.92; exp(β)=1.65, 95% CI 1.07-2.55). Participants in the IT-based arm were less likely to report that 30 minutes of physical activity per day improves health (exp(β)=0.48, 95% CI 0.26-0.90) and more likely to report that vigorous intensity physical activity 3 times per week is essential (exp(β)=1.70, 95% CI 1.02-2.82). The average number of log-ins to the IT platform at 3 and 9 months was 6.99 (SE 0.86) and 9.22 (SE 1.47), respectively. The average number of self-monitoring entries at 3 and 9 months was 16.69 (SE 2.38) and 22.51 (SE 3.79), respectively.

CONCLUSIONS

The ManUp intervention was effective in improving physical activity and dietary behaviors in middle-aged males with no significant differences between IT- and print-based delivery modes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12611000081910; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12611000081910 (Archived by WebCite at http://www.webcitation.org/6QHIWad63).

Effectiveness of a web-based physical activity intervention for adults with Type 2 diabetes-a randomised controlled trial

OBJECTIVE

This study examined the effectiveness of a fully automated web-based programme to increase physical activity in adults with Type 2 diabetes.

METHODS

Between May and July 2010, participants were randomly allocated into either a 12-week intervention (n=195) or a control (n=202) group. Participants were adults diagnosed with Type 2 diabetes, residing in Australia. Participants were assessed at baseline, 12 and 36weeks. The primary physical activity outcome was self-reported minutes of total physical activity. Secondary physical activity outcomes included minutes spent walking, and engaged in moderate, and vigorous physical activity. Additional measures included website satisfaction and website usage. The intervention consisted of a 12-week web-based physical activity intervention developed based on the Theory of Planned Behavior and self-management framework. Data were analysed from 2011 to 2012.

RESULTS

There was a significant group-by-time interaction (X(2) (df=1)=6.37, p<.05) for total physical activity favouring the intervention group d=0.11, for those who completed the intervention, however this was not significant in the intention-to-treat analysis d=0.01. The intervention yielded high website satisfaction and usage.

CONCLUSIONS

In general, there is some evidence for the effectiveness of web-based interventions for improving physical activity levels; however it is clear that maintaining improvements remains an issue.

Healthy weight regulation and eating disorder prevention in high school students: a universal and targeted Web-based intervention

Background

Given the rising rates of obesity in children and adolescents, developing evidence-based weight loss or weight maintenance interventions that can be widely disseminated, well implemented, and are highly scalable is a public health necessity. Such interventions should ensure that adolescents establish healthy weight regulation practices while also reducing eating disorder risk.

Objective

This study describes an online program, StayingFit, which has two tracks for universal and targeted delivery and was designed to enhance healthy living skills, encourage healthy weight regulation, and improve weight/shape concerns among high school adolescents.

Methods

Ninth grade students in two high schools in the San Francisco Bay area and in St Louis were invited to participate. Students who were overweight (body mass index [BMI] >85th percentile) were offered the weight management track of StayingFit; students who were normal weight were offered the healthy habits track. The 12-session program included a monitored discussion group and interactive self-monitoring logs. Measures completed pre- and post-intervention included self-report height and weight, used to calculate BMI percentile for age and sex and standardized BMI (zBMI), Youth Risk Behavior Survey (YRBS) nutrition data, the Weight Concerns Scale, and the Center for Epidemiological Studies Depression Scale.

Results

A total of 336 students provided informed consent and were included in the analyses. The racial breakdown of the sample was as follows: 46.7% (157/336) multiracial/other, 31.0% (104/336) Caucasian, 16.7% (56/336) African American, and 5.7% (19/336) did not specify; 43.5% (146/336) of students identified as Hispanic/Latino. BMI percentile and zBMI significantly decreased among students in the weight management track. BMI percentile and zBMI did not significantly change among students in the healthy habits track, demonstrating that these students maintained their weight. Weight/shape concerns significantly decreased among participants in both tracks who had elevated weight/shape concerns at baseline. Fruit and vegetable consumption increased for both tracks. Physical activity increased among participants in the weight management track, while soda consumption and television time decreased.

Conclusions

Results suggest that an Internet-based, universally delivered, targeted intervention may support healthy weight regulation, improve weight/shape concerns among participants with eating disorders risk, and increase physical activity in high school students. Tailored content and interactive features to encourage behavior change may lead to sustainable improvements in adolescent health.

Systematic literature review of Internet interventions across health behaviors

Purpose: This review examines Internet interventions aiming to change health behaviors in the general population. Methods: Internet health interventions in the USA published between January 2005 and December 2013 were identified through Medline and CINAHL. Keywords used were (Internet or e-health or social media or web) paired with (intervention or program*). A total of 38 articles met all criteria and were reviewed. Results: Studies were analyzed by targeted health behavior interventions: tobacco (5), alcohol (4), weight loss (7), physical activity (PA) (7), nutrition (2), PA and nutrition combined (5), HIV or sexual health (4), and chronic diseases (4). Interventions ranged from one session to 24  weeks (average 6-12 weeks). Common strategies used, including web-based information, tailored feedback, weekly e-mails, goal setting, and self-assessment. Social cognitive theory and the transtheoretical models were the most commonly used frameworks. Recruitment strategies were typically media based varied by settings and populations. Except for the tobacco interventions, the majority studies yielded significant outcomes. Conclusion: This review provides updates and synthesized knowledge on the design and consistent effectiveness of Internet interventions across health behaviors. Results have implications for public health and healthcare professionals, as they play a key role in developing and delivering health promotion interventions as well as in assisting the communities and clients serviced obtaining evidence-based health information.

Effects of a web-based intervention on physical activity and metabolism in older adults: randomized controlled trial

Background

Lack of physical activity leads to detrimental changes in body composition and metabolism, functional decline, and increased risk of disease in old age. The potential of Web-assisted interventions for increasing physical activity and improving metabolism in older individuals holds great promise but to our knowledge it has not been studied.

Objective

The goal of our study was to assess whether a Web-based intervention increases physical activity and improves metabolic health in inactive older adults.

Methods

We conducted a 3-month randomized, waitlist-controlled trial in a volunteer sample of 235 inactive adults aged 60-70 years without diabetes. The intervention group received the Internet program Philips DirectLife, which was directed at increasing physical activity using monitoring and feedback by accelerometer and digital coaching. The primary outcome was relative increase in physical activity measured objectively using ankle- and wrist-worn accelerometers. Secondary outcomes of metabolic health included anthropometric measures and parameters of glucose metabolism.

Results

In total, 226 participants (97%) completed the study. At the ankle, activity counts increased by 46% (standard error [SE] 7%) in the intervention group, compared to 12% (SE 3%) in the control group (P_difference<.001). Measured at the wrist, activity counts increased by 11% (SE 3%) in the intervention group and 5% (SE 2%) in the control group (P_difference=.11). After processing of the data, this corresponded to a daily increase of 11 minutes in moderate-to-vigorous activity in the intervention group versus 0 minutes in the control group (P_difference=.001). Weight decreased significantly more in the intervention group compared to controls (−1.5 kg vs −0.8 kg respectively, P=.046), as did waist circumference (−2.3 cm vs −1.3 cm respectively, P=.036) and fat mass (−0.6% vs 0.07% respectively, P=.025). Furthermore, insulin and HbA1c levels were significantly more reduced in the intervention group compared to controls (both P<.05).

Conclusions

This was the first study to show that in inactive older adults, a 3-month Web-based physical activity intervention was effective in increasing objectively measured daily physical activity and improving metabolic health. Such Web-based interventions provide novel opportunities for large scale prevention of metabolic deregulation in our rapidly aging population.

Trial Registration

Dutch Trial Registry: NTR 3045; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3045 (Archived by WebCite at http://www.webcitation.org/6KPw52dCc).

Multicomponent intervention to reduce daily sedentary time: a randomised controlled trial

OBJECTIVES

To test the efficacy of a multicomponent technology intervention for reducing daily sedentary time and improving cardiometabolic disease risk among sedentary, overweight university employees.

DESIGN

Blinded, randomised controlled trial.

SETTING

A large south-eastern university in the USA.

PARTICIPANTS

49 middle-aged, primarily female, sedentary and overweight adults working in sedentary jobs enrolled in the study. A total of 40 participants completed the study.

INTERVENTIONS

Participants were randomised to either: (1) an intervention group (N=23; 47.6+9.9 years; 94.1% female; 33.2+4.5 kg/m(2)); (2) or wait-list control group (N=17; 42.6+8.9 years; 86.9% female; 31.7+4.9 kg/m(2)). The intervention group received a theory-based, internet-delivered programme, a portable pedal machine at work and a pedometer for 12 weeks. The wait-list control group maintained their behaviours for 12 weeks.

OUTCOME MEASURES

Primary (sedentary and physical activity behaviour measured objectively through StepWatch) and secondary (heart rate, blood pressure, height, weight, waist circumference, per cent body fat, cardiorespiratory fitness, fasting lipids) outcomes were measured at baseline and postintervention (12 weeks). Exploratory outcomes including intervention compliance and process evaluation measures were also assessed postintervention.

RESULTS

Compared to controls, the intervention group reduced daily sedentary time (mean change (95%CI): -58.7 min/day (-118.4 to 0.99; p<0.01)) after adjusting for baseline values and monitor wear time. Intervention participants logged on to the website 71.3% of all intervention days, used the pedal machine 37.7% of all working intervention days and pedalled an average of 31.1 min/day.

CONCLUSIONS

These findings suggest that the intervention was engaging and resulted in reductions in daily sedentary time among full-time sedentary employees. These findings hold public health significance due to the growing number of sedentary jobs and the potential of these technologies in large-scale worksite programmes.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT01371084.

Internet-Based Physical Activity Interventions

This article provides a comprehensive review of Internet- and Website-based physical activity interventions targeting adult populations. Search procedures identified 72 unique Internet-based physical activity interventions published in peer-reviewed journals. Participants of the studies were predominately White, middle-aged (mean age = 43.3 years), and female (65.9%). Intervention durations ranged from 2 weeks to 13 months (median = 12 weeks). Forty-six of the studies were randomized controlled trials, 21 were randomized trials without a control condition, 2 were non-randomized controlled trials, and 3 used a single-group design. The majority of studies (n = 68) assessed outcomes immediately following the end of the intervention period, and 16 studies provided delayed postintervention assessments. Forty-four of the 72 studies (61.1%) reported significant increases in physical activity. Future directions for Internet-based physical activity interventions include increasing representation of minority and male populations in Internet-based efforts, conducting delayed postintervention follow-up assessments, and incorporating emerging technologies (ie, cellular and Smartphones) into Internet-based physical activity efforts.

Interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people

BACKGROUND

The World Health Organization (WHO) estimates that the number of obese or overweight individuals worldwide will increase to 1.5 billion by 2015. Chronic diseases associated with overweight or obesity include diabetes, heart disease, hypertension and stroke.

OBJECTIVES

To assess the effects of interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people.

SEARCH METHODS

We searched several electronic databases, including CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and PsycINFO, through 25 May 2011. We also searched clinical trials registries to identify studies. We scanned reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Studies were included if they were randomized controlled trials or quasi-randomized controlled trials that evaluated interactive computer-based weight loss or weight maintenance programs in adults with overweight or obesity. We excluded trials if the duration of the intervention was less than four weeks or the loss to follow-up was greater than 20% overall.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted study data and assessed risk of bias. Where interventions, control conditions, outcomes and time frames were similar between studies, we combined study data using meta-analysis.

MAIN RESULTS

We included 14 weight loss studies with a total of 2537 participants, and four weight maintenance studies with a total of 1603 participants. Treatment duration was between four weeks and 30 months. At six months, computer-based interventions led to greater weight loss than minimal interventions (mean difference (MD) -1.5 kg; 95% confidence interval (CI) -2.1 to -0.9; two trials) but less weight loss than in-person treatment (MD 2.1 kg; 95% CI 0.8 to 3.4; one trial). At six months, computer-based interventions were superior to a minimal control intervention in limiting weight regain (MD -0.7 kg; 95% CI -1.2 to -0.2; two trials), but not superior to infrequent in-person treatment (MD 0.5 kg; 95% -0.5 to 1.6; two trials). We did not observe consistent differences in dietary or physical activity behaviors between intervention and control groups in either weight loss or weight maintenance trials. Three weight loss studies estimated the costs of computer-based interventions compared to usual care, however two of the studies were 11 and 28 years old, and recent advances in technology render these estimates unlikely to be applicable to current or future interventions, while the third study was conducted in active duty military personnel, and it is unclear whether the costs are relevant to other settings. One weight loss study reported the cost-effectiveness ratio for a weekly in-person weight loss intervention relative to a computer-based intervention as USD 7177 (EUR 5678) per life year gained (80% CI USD 3055 to USD 60,291 (EUR 2417 to EUR 47,702)). It is unclear whether this could be extrapolated to other studies. No data were identified on adverse events, morbidity, complications or health-related quality of life.

AUTHORS' CONCLUSIONS

Compared to no intervention or minimal interventions (pamphlets, usual care), interactive computer-based interventions are an effective intervention for weight loss and weight maintenance. Compared to in-person interventions, interactive computer-based interventions result in smaller weight losses and lower levels of weight maintenance. The amount of additional weight loss, however, is relatively small and of brief duration, making the clinical significance of these differences unclear.

Randomized controlled trial testing an internet physical activity intervention for sedentary adults

OBJECTIVE

Internet-based physical activity (PA) interventions have shown promise, although findings remain equivocal. We used formative research to enhance a previously demonstrated program (Step into Motion) with the goal of developing an Internet program poised for dissemination.

METHODS

We conducted focus groups to identify Internet features targeted to theoretical constructs (social cognitive theory) predictive of PA behavior and rated as "useful for increasing PA." We identified 5 theory-targeted Internet features as useful for increasing PA: (1) a PA tracking/logging calendar targeting self-monitoring and goal setting; (2) geographic mapping tools targeting perceived environment; (3) a discussion forum targeting social support; (4) exercise videos targeting observational learning; and (5) regular updates of peer PA progress targeting situation. We then tested the efficacy of the enhanced program (enhanced Internet, EI; N = 25) in relation to publicly available PA Websites (standard Internet, SI; N = 28) among 53 participants in a randomized controlled trial.

RESULTS

The EI arm increased PA in relation to the SI arm at 3 months (18.4 to 186.0 min/wk vs. 20.9 to 57.3 min/wk; p = .03) but between-groups differences were not observed at 6 months (176.8 vs. 133.5 min/wk; p = .44). EI participants maintained PA from 3 to 6 months (186.0 to 176.8 min/wk), and the SI group increased PA (57.3 to 133.5 min/wk).

CONCLUSION

The EI program was efficacious at improving PA levels in relation to publicly available Websites initially, but differences in PA levels were not maintained at 6 months. Future research should identify Internet features that promote long-term maintenance.

Meta-analysis of internet-delivered interventions to increase physical activity levels

Many internet-delivered physical activity behaviour change programs have been developed and evaluated. However, further evidence is required to ascertain the overall effectiveness of such interventions. The objective of the present review was to evaluate the effectiveness of internet-delivered interventions to increase physical activity, whilst also examining the effect of intervention moderators. A systematic search strategy identified relevant studies published in the English-language from Pubmed, Proquest, Scopus, PsychINFO, CINHAL, and Sport Discuss (January 1990 - June 2011). Eligible studies were required to include an internet-delivered intervention, target an adult population, measure and target physical activity as an outcome variable, and include a comparison group that did not receive internet-delivered materials. Studies were coded independently by two investigators. Overall effect sizes were combined based on the fixed effect model. Homogeneity and subsequent exploratory moderator analysis was undertaken. A total of 34 articles were identified for inclusion. The overall mean effect of internet-delivered interventions on physical activity was d = 0.14 (p = 0.00). Fixed-effect analysis revealed significant heterogeneity across studies (Q = 73.75; p = 0.00). Moderating variables such as larger sample size, screening for baseline physical activity levels and the inclusion of educational components significantly increased intervention effectiveness. Results of the meta-analysis support the delivery of internet-delivered interventions in producing positive changes in physical activity, however effect sizes were small. The ability of internet-delivered interventions to produce meaningful change in long-term physical activity remains unclear.

Reductions in employee productivity impairment observed after implementation of web-based worksite health promotion programs

OBJECTIVE

To assess changes in employee productivity impairment observed after the implementation of several Web-based health promotion programs.

METHODS

Health risk assessments and self-report measures of productivity impairment were administered on-line to more than 43,000 participants of Web-based health promotion programs.

RESULTS

Reductions in productivity impairment were observed after 1 month of program utilization. Productivity impairment at 90- and 180-day follow-ups also decreased relative to baseline. Improvements in employee health were associated with reductions in employee productivity impairment.

CONCLUSION

The use of Web-based health promotion programs was associated with reductions in productivity impairment and improvements in employee health. After the implementation of Web-based health promotion programs, reductions in productivity impairment may be observed before reductions in direct health care costs.

Systematic review and evaluation of web-accessible tools for management of diabetes and related cardiovascular risk factors by patients and healthcare providers

Objective

To identify and evaluate the effectiveness, clinical usefulness, sustainability, and usability of web-compatible diabetes-related tools.

Data sources

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, world wide web.

Study selection

Studies were included if they described an electronic audiovisual tool used as a means to educate patients, care givers, or clinicians about diabetes management and assessed a psychological, behavioral, or clinical outcome.

Data extraction

Study abstraction and evaluation for clinical usefulness, sustainability, and usability were performed by two independent reviewers.

Results

Of 12616 citations and 1541 full-text articles reviewed, 57 studies met inclusion criteria. Forty studies used experimental designs (25 randomized controlled trials, one controlled clinical trial, 14 before–after studies), and 17 used observational designs. Methodological quality and ratings for clinical usefulness and sustainability were variable, and there was a high prevalence of usability errors. Tools showed moderate but inconsistent effects on a variety of psychological and clinical outcomes including HbA1c and weight. Meta-regression of adequately reported studies (12 studies, 2731 participants) demonstrated that, although the interventions studied resulted in positive outcomes, this was not moderated by clinical usefulness nor usability.

Limitation

This review is limited by the number of accessible tools, exclusion of tools for mobile devices, study quality, and the use of non-validated scales.

Conclusion

Few tools were identified that met our criteria for effectiveness, usefulness, sustainability, and usability. Priority areas include identifying strategies to minimize website attrition and enabling patients and clinicians to make informed decisions about website choice by encouraging reporting of website quality indicators.

The effect of computers for weight loss: a systematic review and meta-analysis of randomized trials

BACKGROUND

The use of computers to deliver education and support strategies has been shown to be effective in a variety of conditions. We conducted a systematic review and meta-analysis to evaluate the impact of computer-based technology on interventions for reducing weight.

METHODS

We searched MEDLINE, CENTRAL, CINAHL, PsycINFO, Google Scholar and ClinicalTrials.gov (all updated through June 2010) for randomized controlled trials evaluating the effect of computer-based technology on education or support interventions aimed at reducing weight in overweight or obese adults. We calculated weighted mean differences (WMD) and 95% confidence intervals (CI) using random effects models.

RESULTS

Eleven trials with 13 comparisons met inclusion criteria. Based on six comparisons, subjects who received a computer-based intervention as an addition to the standard intervention given to both groups lost significantly more weight (WMD -1.48 kg, 95% CI -2.52, -0.43). Conversely, based on six comparisons, subjects for whom computer-based technology was substituted to deliver an identical or highly comparable intervention to that of the control group lost significantly less weight (WMD 1.47 kg, 95% CI 0.13, 2.81). Significantly different weight loss seen in "addition" comparisons with less than six months of follow-up (WMD -1.95 kg, 95% CI -3.50, -0.40, two comparisons) was not seen in comparisons with longer follow-up (-1.08 kg, 95% CI -2.50, 0.34, four comparisons). Analyses based on quality and publication date did not substantially differ.

CONCLUSIONS

While the addition of computer-based technology to weight loss interventions led to statistically greater weight loss, the magnitude (<1.5 kg) was small and unsustained.