Refinement and Pilot Testing Social Networks for Encouraging Healthy Behaviors: The Social Pounds Off Digitally (Social POD) Study

Currently about 71% of adults in the US are considered overweight or obese. Overweight and obesity are associated with higher risk of developing many chronic diseases; however, health risks associated with overweight and obesity can be reduced by as little as a 3% to 5% reduction in weight. Mobile health (mHealth) has shown promise as a way to deliver weight loss interventions, yet maintaining participant engagement over time has been a challenge. The purpose of this study was to develop, refine, and pilot test the Social Pounds Off Digitally (POD) Android app for personalized health monitoring and interaction; revise the Social POD app based on participant feedback; and conduct a multi-site randomized clinical trial to pilot test the second iteration of the Social POD app. Overweight and obese adults with Android smartphones (BMI 25-49.9 kg/m2; N=9) were recruited for a two-month weight loss pilot intervention and iterative usability testing of the Social POD app. The app prompted participants via notification to track daily weight, diet, and PA behaviors. Participants received the content of the behavioral weight loss intervention via podcast. In order to re-engage infrequent users, the app prompted frequent app users to select one of three messages to send to infrequent users targeting one of three behavioral theory constructs: 1) social support, 2) self-efficacy, or 3) negative outcome expectations. Body weight and dietary intake (two 24-hr recalls) were assessed at baseline and two months. All participants attended one of two focus groups to provide feedback on use of the app. Based on the usability testing, the Social POD app was refined and a point-based incentive system was incorporated into the app and used in a larger randomized controlled trial. Overweight and obese adults (N=51, mean BMI=34.7 ± 6.0, 38% black) in Charleston and Columbia, SC who owned an Android phone or tablet were recruited to participate in a 12-week behavioral weight loss intervention delivered via mobile app and podcast. All participants received the behavioral content of the weight loss intervention via twice weekly podcasts and were randomized to download and use either a standard calorie tracking app (Fat Secret) or the Social POD app. Main outcomes included kilograms lost at 12-weeks and secondary outcomes included change in psychosocial variable scores from pre- to post-test, association between points earned and percent weight loss at 12-weeks, and reengagement based on message-type received. Following the usability testing participants lost a mean of -0.94 kg (±2.22 kg, p=0.24) and consumed significantly fewer kcals post-intervention (1570±508 kcal/day) as compared to baseline (2384±993 kcal/day, p=0.01). Mean number of app entries was 77.2 ± 73.8 per person with a range of 2 to 219. Messages selected and sent to infrequent users targeting social support were sent most frequently (n=32, 46%), followed by self-efficacy (n=29, 40%), and negative outcome expectations (n=10, 14%). Themes from the focus groups included functionality issues, revisions to the messaging system, and the addition of a point system with rewards for achieving goals. Participant attrition for the RCT was 12% (n=3 experimental and n=3 comparison). Experimental group participants lost significantly more weight (-5.3kg, CI: vi i -7.5, -3.0) than comparison group participants (-2.23kg, CI: -3.6, -1.0; p=0.02) and had a greater reduction in BMI (p=0.02). These outcomes were significant for both intentionto- treat (using baseline observation carried forward) and complete case. While there were significant differences in final positive outcome expectations scores between groups [4.56 experimental, 3.57 comparison (scale range from 1 to 7, maximum); p=0.04], other secondary outcomes (e.g., caloric intake and social support) were not significantly different by group assignment while controlling for baseline values. Among experimental group participants only, total points earned significantly predicted percent weight loss (B=-0.02, p=0.01). In addition, higher scores for the conscientiousness personality trait was significantly associated with total points earned (B=9.07, p=0.03), but other personality characteristics and demographics were not. Messages most frequently sent to infrequent users of the Social POD app were social support (n=119), followed by outcome expectations (n=99), and then messages targeting self-efficacy (n=97). There was a significant difference between the type of message received and re-engagement among infrequent users (p=0.03) with self-efficacy messages prompting the most engagement (n=7), followed by outcome expectation messages (n=5) and social support messages (n=1). In conclusion, use of the Social POD app led to greater weight loss than a standard diet-tracking app (Fat Secret). This mobile health intervention has the potential to be widely disseminated to reduce the risk of chronic disease associated with overweight and obesity

Advancing Dietetic Practice through the Implementation and Integration of Smartphone Apps

As the burden of obesity and its related chronic diseases grows, dietitians have integral roles in providing individualised medical nutrition therapy. Smartphone mobile health (mHealth) applications (apps) have potential to support and extend reach of dietetic services. This thesis examines how mHealth apps could be implemented and integrated by dietitians to advance nutrition care. Based on a narrative review of current evidence, the novel mobile Nutrition Care Process grid was developed, providing dietitians with best-practice guidance for using mHealth apps across the nutrition care process. Surveying dietitians internationally revealed that 62% used mHealth apps in their practice, although primarily as an information resource and for patient self-monitoring rather than as an integral part of the nutrition care process. Similarly, the public used commercial health and fitness apps, such as MyFitnessPal, to track health behaviours. However, individuals performed suboptimally when using MyFitnessPal to track dietary intake, with the app underestimating mean energy intake by -1863kJ (SD=2952kJ, P=0.0002) compared to 24-hour recalls. Qualitative feedback from dietitians, the public and patients are presented to guide app developers in designing quality mHealth apps. A behavioural analysis was conducted using the COM-B model and intervention recommendations were formulated to facilitate uptake of mHealth apps into dietetic practice. These recommendations were incorporated into a two-phase intervention comprising of an educational and training workshop and a 12-week phase where dietitians used an integrated commercial app platform with their patients. The intervention was found to be feasible to deliver and improved dietitians’ mHealth app self-efficacy. There is translational potential for this intervention to equip the profession with greater capability, opportunity, motivation and self-efficacy to use mHealth apps in dietetic practice and in patient nutrition care

Comparison of traditional versus mobile app self-monitoring of physical activity and dietary intake among overweight adults participating in an mHealth weight loss program

Self-monitoring of physical activity (PA) and diet are key components of behavioral weight loss programs. The purpose of this study was to assess the relationship between diet (mobile app, website, or paper journal) and PA (mobile app vs no mobile app) self-monitoring and dietary and PA behaviors

Effect of Using the Snackability Smartphone Application to Improve the Quality of Snack Intake, General Diet Quality, and Weight among College Students

College is a challenging period to make healthy food and snack choices and this could lead to poor diet quality and weight gain in the future. The Snackability application (app) was developed using the Social Cognitive Theory for behavior change to help students choose healthy snacks based on the USDA guidelines. The objective of this study was to determine whether the app improved snack, diet quality, and body weight in overweight and obese college students within a two-arm, 12-week randomized controlled trial (RCT). A total of 139 participants completed all baseline measures and were randomized into the control or app groups. Baseline characteristics were similar between groups. Overall, mean age was 21.1 (1.7) years, 84.6% were females, 30.9% were Hispanic, 51.1% had an income less than $50,000, and mean BMI was 30.4 (5.6) kg/m2. Participants in the app group significantly increased snack score at week 4 (

Potential Use of Mobile Phone Applications for Self-Monitoring and Increasing Daily Fruit and Vegetable Consumption: A Systematized Review

A wide range of chronic diseases could be prevented through healthy lifestyle choices, such as consuming five portions of fruits and vegetables daily, although the majority of the adult population does not meet this recommendation. The use of mobile phone applications for health purposes has greatly increased; these applications guide users in real time through various phases of behavioural change. This review aimed to assess the potential of self-monitoring mobile phone health (mHealth) applications to increase fruit and vegetable intake. PubMed and Web of Science were used to conduct this systematized review, and the inclusion criteria were: randomized controlled trials evaluating mobile phone applications focused on increasing fruit and/or vegetable intake as a primary or secondary outcome performed from 2008 to 2018. Eight studies were included in the final assessment. The interventions described in six of these studies were effective in increasing fruit and/or vegetable intake. Targeting stratified populations and using long-lasting interventions were identified as key aspects that could influence the effectiveness of these interventions. In conclusion, evidence shows the effectiveness of mHealth application interventions to increase fruit and vegetable consumption. Further research is needed to design effective interventions and to determine their efficacy over the long term

Effectiveness and Feasibility of a Remote Lifestyle Intervention by Dietitians for Overweight and Obese Adults: Pilot Study

BACKGROUND To tackle the problem of obesity and related diseases in Switzerland, cost-efficient, effective, and innovative primary health care interventions for weight management are required. In this context, Oviva has developed a scalable technology for registered dietitians to counsel overweight and obese patients via a mobile phone app. OBJECTIVE The aim of this study was to evaluate the effectiveness and feasibility of weight loss counseling by dietitians using a mobile phone app for patients with overweight and obesity. METHODS In this pre- and posttest pilot study, overweight and obese adults participated in a 1-year behavioral intervention to lose weight through remote counseling by dietitians in the German-speaking part of Switzerland. The study started in April 2016 and finished in May 2018. Participants received individual counseling through the app and the exchange with the dietitian focused on regular feedback on photo-based food log, motivation, and education. The contents were tailored to the individual lifestyle goal set. The predefined intensity of remote counseling decreased during the year. Group chat could be used. The outcomes examined were changes in weight (primary outcome), hemoglobin A1c, fasting glucose, fasting insulin, triglyceride, high-density lipoprotein cholesterol, blood pressure (BP), body mass index (BMI), waist circumference, body fat, and responses to a self-administered questionnaire with questions regarding participants' physical activity, dietary assessment, and health-related quality of life. Changes were tested at baseline, after 3 months, and after 12 months, as well as between the third and the 12th month. RESULTS In total, 36 women and 7 men, with a mean age of 40.6 years, participated and 36 participants completed the study. Median weight change after the first 12 weeks was -3.8 kg (range: -15 to 2.4 and P<.001), between week 12 and week 52 it was -1.1 kg (range: -9.7 to 7 and P=.08), and the median change during the entire period of intervention was -4.9 kg (range: -21.9 to 7.5 and P<.001). Furthermore, changes in BMI, waist circumference, body fat, and BP between baseline and 12 weeks and between baseline and 52 weeks were also significant. Significant changes in certain eating habits were also demonstrated (higher frequency of vegetable, fruit, and breakfast consumption and lower frequency of alcohol, sweet, and fat consumption). CONCLUSIONS In addition to the professional skills of a dietitian, a profession-specific app such as Oviva can provide effective support that meets the needs of dietitians and clients on the long path of behavioral change and sustainable weight reduction. TRIAL REGISTRATION ClinicalTrials.gov NCT02694614; https://clinicaltrials.gov/ct2/show/NCT02694614 (Archived by WebCite at http://www.webcitation.org/76gYkGOIc)

A comparison of video conferencing and in-person health coaching approaches in combination with mHealth devices on weight loss, physical activity, and glycemic control

Background: Compare health coaching efficacy on weight loss, physical activity, and glycemic control between individualized video conferencing (VC), in-person (IP) and control (CG) groups of adults with high BMI. Methods: Thirty adults (BMI≥30 kg/m2) were randomly assigned to create three groups of 10 members each. Participants received a wireless accelerometer watch and weight scale to sync with their personal smartphones and downloaded apps. Participants assigned to VC and IP received weekly health coaching individualized based on data uploaded over the 12-wk intervention. Steps/day and weight loss were analyzed via analyses of covariance (ANCOVA). Between-group ANOVAs analyzed post-intervention changes in weight (kg), glucose, HbA1c, and HOMA-IR. Results: Weight loss (8.23±4.5kg; 7.7%) was greater (pp≤.05); VC consistently had the higher step/day averages. No between-group differences were found for any glycemic control markers. Conclusion: Our innovative, multidisciplinary, telemedicine health coaching delivered through video conferencing led to favorable changes in weight loss, physical activity, and HOMA-IR that surpassed changes when health coaching was delivered in person or was absent. Future studies using video conferencing to investigate health coaching delivered in group and individualized formats and for other population subgroups are needed as are studies investigating the impact of weight loss on other health outcomes (e.g. lipid profile, glycemic control, and inflammatory markers)

Healthy Motivations for Moms-To-Be (Healthy MoM2B) Study: A Mobile Health Intervention Targeting Gestational Weight Gain among U.S. Women

INTRODUCTION: Almost one-half of all pregnant women in the U.S. exceed the Institute of Medicine’s (IOM) gestational weight gain (GWG) guidelines. Healthy GWG is critical for reducing adverse health outcomes associated with excessive GWG for the mother and infant. Electronic health (e-health) interventions delivered through mobile apps and websites hold potential as readily available resources for targeting health behaviors and monitoring GWG during pregnancy. The development of the Healthy Motivations for Moms-To-Be (HM2B) intervention was informed by health behavior theories, a systematic review of existing in-person and technology mediated interventions (Aim 1 of this dissertation), and results of an online needs assessment (Aim 2) of pregnant women’s weight-related knowledge, behaviors, interests in various e-health intervention components. Participants were randomized to receive one of two intervention conditions (Aim 3). Participants in the Healthy Eating and Physical Activity (HEPA) condition received targeted GWG goals (based on pre-pregnancy Body Mass Index (BMI)), as well as evidence-based behavioral strategies to encourage healthy GWG, while the comparison condition received content related to Stress Reduction and Management (SRAM) techniques to reduce overall stress levels during pregnancy. Participants used a study website to track individual health behaviors and outcomes respective of their study conditions, access informational podcasts, and read weekly tips for having a healthy pregnancy. The website was developed by the TecHealth Center. In addition, participants were assigned to a group of 8-10 other pregnant women and virtually connected through a commercially-available free mobile app called MakeMe, for 12 consecutive weeks. Each week, participants were provided a behavioral goal to aim for on 5 of the 7 days during the week. Social support elements (i.e., comments and “thumbs up” to teammates’ activity) were included in the mobile app to encourage participation, social support, and maintenance of the behavioral goal. The purpose of this study was determine the impact of a mobile health intervention, Healthy Motivations for Moms-To-Be (HM2B), targeting healthy eating and physical activity (HEPA) on GWG and increase the proportion of women who gain within the Institute of Medicine’s (IOM) guidelines for healthy gestational weight gain (GWG). METHODS: Healthy pregnant women (N=140) living in the U.S. were recruited through social media to participate in a randomized controlled electronic health intervention, which consisted of a mobile app for facilitating group-based healthy behavior challenges and a website for tracking health outcomes (i.e., GWG). The intervention condition targeted HEPA behaviors during pregnancy, while the comparison condition focused on stress reduction and management during pregnancy. Pre-pregnancy weight and weight at delivery were self-reported to determine GWG in relation to IOM guidelines. Participants completed online surveys at baseline (\u3c20 weeks) and upon completion of the 12 week group-based intervention. Surveys included the Rapid Eating Assessment for Participants-Shortened (REAP-S) scale for measuring typical dietary intake. RESULTS: Participants who completed their delivery outcomes survey were included in the analysis (n=87). The sample was predominately white (81.6%) and highly educated (advanced degree beyond Bachelor’s; 58.6%). Regarding adherence to IOM guidelines, there was a promising but not significant difference in the proportion of women gaining adequate weight in the intervention versus comparison group (36% vs. 25%) or in the proportion of women who exceeded IOM guidelines (43% vs. 53%, respectively, p=0.42). There was a significant difference observed in post-intervention healthy eating behaviors reported between groups (F (1,87)=4.07, p=0.047), where HEPA participants reported healthier eating scores on the Rapid Eating Assessment for Participants (REAP) scale. CONCLUSIONS: Although the effect of the intervention on reducing excessive GWG was not significant, the HM2B study demonstrated potential in facilitating healthy behavior change through group-based goal setting and self-monitoring using a mobile app. Future studies should explore opportunities for increasing user engagement and interaction for sustained use of eHealth interventions

Meta-analysis: The Effectiveness of mHealth Mobile Application Use to Promote Physical Activity and Ideal Body Weight in Adult with Overweight

Background: Globally, overweight and obesity are significant contributors to morbidity and mortality, which in turn can reduce productivity and increase the burden of healthcare costs. Interventions to treat obesity include a comprehensive lifestyle approach (diet, physical activity, and behavioral therapy) to achieve and maintain weight loss. One method for monitoring weight loss program interventions is the use of a mobile health application (mHealth). This study aims to analyze the effectiveness of using mHealth on increasing physical activity and losing weight. Subjects and Method: This research is a meta-analysis study using PRISMA flowchart guidelines. The article search process was carried out between 2011 and 2021 using databases from PubMed, Google Scholar and ScienceDirect. Based on the database, there were 15 articles that met the inclusion criteria. The analysis was carried out using the RevMan 5.3 . software. Results: Meta-analysis of 9 randomized controlled trial articles showed that overall mHealth increased physical activity by 0.19 compared to controls (SMD = 0.19; 95% CI= 0.06 to 0.32; p = 0.004). Higher intervention outcomes were obtained from interventions for more than 3 months (SMD = 0.31; 95% CI = 0.13 to 0.49; p < 0.001). Short-term effects for 3 months did not show significant results. A meta-analysis of 15 randomized controlled trial articles concluded that the use of mHealth overall was able to reduce body weight by 0.34 compared with no use of the mHealth application (SMD = -0.34; 95% CI = -0.52 to -0.17; p< 0.001). Higher intervention outcomes were obtained from the 6-month intervention (SMD= -0.52; 95% CI= -0.82 to -0.22; p < 0.001). Short-term effects for 3 months did not show significant results. Conclusion: Long-term use of the mHealth app is effective for increasing physical activity and losing weight in overweight adults. However, the effect of short-term intervention for 3 months has not shown significant result.. Keywords: mHealth, weight loss, physical activity. Correspondence: Farida Nur Aisyiyah. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta 57126, Central Java. Email: [email protected]. Mobile: +62 852-1493-3173.   Journal of Health Promotion and Behavior, (2022), 07(03): 208-224 DOI: https://doi.org/10.26911/thejhpb.2022.07.03.0