Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Miranda, Jaime. Universidad Peruana Cayetano Heredia; PerúFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants \u3c40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today\u27s young adults. Keywords: cardiovascular disease prevention; cardiovascular disease risk factors; primary prevention; young adults

Persuasive digital health technologies for lifestyle behaviour change

BACKGROUND. Unhealthy lifestyle behaviours such as physical inactivity are global risk factors for chronic disease. Despite this, a substantial proportion of the UK population fail to achieve the recommended levels of physical activity. This may partly be because the health messages presently disseminated are not sufficiently potent to evoke behaviour change. There has been an exponential growth in the availability of digital health technologies within the consumer marketplace. This influx of technology has allowed people to self-monitor a plethora of health indices, such as their physical activity, in real-time. However, changing movement behaviours is difficult and often predicated on the assumption that individuals are willing to change their lifestyles today to reduce the risk of developing disease years or even decades later. One approach that may help overcome this challenge is to present physiological feedback in parallel with physical activity feedback. In combination, this approach may help people to observe the acute health benefits of being more physically active and subsequently translate that insight into a more physically active lifestyle. AIMS. Study One aimed to review existing studies employing fMRI to examine neurological responses to health messages pertaining to physical activity, sedentary behaviour, smoking, diet and alcohol consumption to assess the capacity for fMRI to assist in evaluating health behaviours. Study Two aimed to use fMRI to evaluate physical activity, sedentary behaviour and glucose feedback obtained through wearable digital health technologies and to explore associations between activated brain regions and subsequent changes in behaviour. Study Three aimed to explore engagement of people at risk of type 2 diabetes using digital health technologies to monitor physical activity and glucose levels. METHODS. Study One was a systematic review of published studies investigating health messages relating to physical activity, sedentary behaviour, diet, smoking or alcohol consumption using fMRI. Study Two asked adults aged 30-60 years to undergo fMRI whilst presented personalised feedback on their physical activity, sedentary behaviour and glucose levels, following a 14-day wear protocol of an accelerometer, inclinometer and flash glucose monitor. Study Three was a six-week, three-armed randomised feasibility trial for individuals at moderate-to-high risk of developing type 2 diabetes. The study used commercially available wearable physical activity (Fitbit Charge 2) and flash glucose (Freestyle Libre) technologies. Group 1 were offered glucose feedback for 4 weeks followed by glucose plus physical activity feedback for 2 weeks (G4GPA2). Group 2 were offered physical activity feedback for 4 weeks followed by glucose plus physical activity feedback for 2 weeks (PA4GPA2). Group 3 were offered glucose plus physical activity feedback for six weeks (GPA6). The primary outcome for the study was engagement, measured objectively by time spent on the Fitbit app, LibreLink app (companion app for the Freestyle Libre) as well as the frequency of scanning the Freestyle Libre and syncing the Fitbit. RESULTS. For Study One, 18 studies were included in the systematic review and of those, 15 examined neurological responses to smoking related health messages. The remaining three studies examined health messages about diet (k=2) and physical activity (k=1). Areas of the prefrontal cortex and amygdala were most commonly activated with increased activation of the ventromedial prefrontal cortex predicting subsequent behaviour (e.g. smoking cessation). Study Two identified that presenting people with personalised feedback relating to interstitial glucose levels resulted in significantly more brain activation when compared with feedback on personalised movement behaviours (P<.001). Activations within regions of the prefrontal cortex were significantly greater for glucose feedback compared with feedback on personalised movement behaviours. Activation in the subgyral area was correlated with moderate-to-vigorous physical activity at follow-up (r=.392, P=.043). In Study Three, time spent on the LibreLink app significantly reduced for G4GPA2 and GPA6 (week 1: 20.2±20 versus week 6: 9.4±14.6min/day, p=.007) and significantly fewer glucose scans were recorded (week 1: 9.2±5.1 versus week 6: 5.9±3.4 scans/day, p=.016). Similarly, Fitbit app usage significantly reduced (week 1: 7.1±3.8 versus week 6: 3.8±2.9min/day p=.003). The number of Fitbit syncs did not change significantly (week 1: 6.9±7.8 versus week 6: 6.5±10.2 syncs/day, p=.752). CONCLUSIONS. Study One highlighted the fact that thus far the field has focused on examining neurological responses to health messages using fMRI for smoking with important knowledge gaps in the neurological evaluation of health messages for other lifestyle behaviours. The prefrontal cortex and amygdala were most commonly activated in response to health messages. Using fMRI, Study Two was able to contribute to the knowledge gaps identified in Study One, with personalised glucose feedback resulting in a greater neurological response than personalised feedback on physical activity and sedentary behaviour. From this, Study Three found that individuals at risk of developing type 2 diabetes were able to engage with digital health technologies offering real-time feedback on behaviour and physiology, with engagement diminishing over time. Overall, this thesis demonstrates the potential for digital health technologies to play a key role in feedback paradigms relating to chronic disease prevention

Replacing Sedentary Behavior with a Light Intensity Physical Activity in the Homes of Older Adults

Aging is positively correlated with time spent in sedentary behavior (SB), which has been found to be linked to premature mortality, cardiovascular disease risk, and functional limitations. Moderate-to-vigorous-intensity physical activity (MVPA) is a potent stimulus for preventing and improving functional limitations in older adults, but less than 17% of the older adult population meets the recommended PA guidelines. While increased time spent in SB is detrimental to health in all, the impact among those that are physically inactive appear to be most pronounced. Recent evidence suggests increasing light-intensity physical activity (LPA) in these populations may provide health benefits and could be a more practical approach for older adults. The purpose of this dissertation project is to identify safe, effective, and practical evidence-based approaches to reduce SB to maintain or improve physical function in late life. Therefore, the aims of this dissertation project are three fold: 1) to identify the impact of replacing time spent in SB with physical activity on measures of physical function in community-dwelling older adults, 2) identify the feasibility of using a seated portable elliptical device (SED) in the homes of older adults, and 3) determine the effectiveness of using a SED to replace time spent in SB with a LPA and explore the impact on measures of physical function in older adults. An isotemporal substitution regression model identified that replacing as little as 30 minutes of SB with LPA led to significant improvements in walking speed. Meanwhile, replacing up to 60 minutes of SB with LPA led to larger magnitudes of improvement which approached clinical relevance. Further, supplementing LPA with MVPA progressively increased the improvements in a battery of functional assessments. Interventions to reduce SB have come with difficulty and methods to purposefully replace SB with PA should be developed to test the validity of the findings from these novel statistical models. A seated elliptical pedaling device (SED) was used to purposefully target reducing SB and replacing with LPA, while allowing participants to maintain the enjoyment of their typically passive activity in their home. A one week trial study identified that there was no difference in the ability of older adults to accumulate between 15 to 60 minutes of pedaling per day. Further, there was high acceptability among all participants that were randomly assigned to either 15, 30, 45, or 60 minutes per day pedaling groups. This led to the development of an 8-week pilot randomized controlled trial using the SED. In this trial, the intervention was effective at replacing SB with LPA as identified by a group by time interaction effect. Specifically, the elliptical group (EG) experienced a significant 7.3% (p = 0.003) reduction in daily SB and 7.1% (p = 0.002) increase in LPA between baseline and follow-up testing compared to no significant difference in the control group (CG). Participants suggested improvements in function, but small effect sizes and sample sizes did not produce significant improvements in measures of physical function. Introducing a SED during passive activities in the home is a feasible and effective approach at reducing daily SB in older adults. While some of the functional tests did exhibit ceiling effects among those that were high functioning at baseline, subjective responses from individuals of lower functioning suggest the potential for impacting the QOL of those that have difficulty performing ambulatory activities. Future investigations using the SED should be directed toward longer intervention periods, with larger sample sizes, and among individuals of various levels of functional ability and life circumstances

Planning, developing, and pilot testing a mobile health promotion program to prevent type 2 diabetes after gestational diabetes mellitus

Background: Gestational diabetes mellitus (GDM) is associated with an increased risk for type 2 diabetes (T2D) and related cardiometabolic disturbances. A healthy lifestyle with sufficient physical activity, a balanced nutrition, and psychosocial wellbeing decreases the risk of developing these conditions in the years following delivery. Current prevention programs for women after GDM insufficiently address the needs of a flexible, accessible, and practical tool for daily life in this target group. The aim of this dissertation project was to create a theory- and evidence-based scalable mobile health (mHealth) application that fulfils both academic and industrial standards, supports behavior change, and addresses the specific needs of women post-GDM. Methods: The Intervention Mapping approach was implemented to structure the development process. In the scope of this thesis, Intervention Mapping Steps 1 to 4 were applied as blueprint and analytical tool for planning, developing, and pilot testing the smartphone-based TRANGLE program to prevent T2D and related cardiometabolic disturbances in women post-GDM. In the Steps 1 to 3, we designed a theory- and evidence-based intervention model. In Step 4, we cooperated with industry to secure a high technological standard when translating the model into a practical intervention based on a smartphone app. For the associated user study and the clinical pilot trial, we used a mixed methods design based on validated questionnaires on user acceptance and lifestyle behavior, user logs, think alouds with semi-structured interviews, nutrition protocols, and clinical assessments. Results: The resulting TRIANGLE program is among the first mHealth apps for personalized stepwise habit change in the areas of physical activity, nutrition, and psychosocial wellbeing. The interactive app allows for self-pacing, addresses 11 behavioral determinants, and offers 39 behavior change methods to support individual lifestyle change. An associated online platform for healthcare practitioners allows for human coaching while a unique challenge system fosters habit change and education. Once a beta-version of the app and the coaching platform was available, the iterative development process comprised a user study with women post-GDM, followed by adaptations before the full program production. Lastly, a German multicenter randomized controlled pilot trial of the TRIANGLE program indicated first clinical effects for behavior change after six months of intervention. Women post-GDM showed a high acceptance and a high perceived impact of the program on their behavior. Conclusions: Using the Intervention Mapping approach, we developed an innovative mHealth solution for women post-GDM. The novel TRIANGLE program has the potential to prevent cardiometabolic disease as an easy to deliver technological support for behavior change. The program needs to be further refined and tested at a large scale. Intervention Mapping Steps 5 and 6 may support this implementation and evaluation process

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases