TEXT ME: Lifestyle-Modification App May Improve LDL Cholesterol, Other CVD Risk Factors

Deborah Brauser

September 22, 2015

SYDNEY, AUSTRALIA — There's an app for that! Receiving lifestyle-reminder texts via smartphone may improve cardiovascular disease risk factors in patients with CHD, suggests new research[1].

The randomized Tobacco, Exercise and Diet Messages (TEXT ME) trial included more than 700 adults in Australia. It showed that, compared with the participants who received usual care only, those who received usual care plus four motivational texts weekly for 6 months had greater improvement in low-density lipoprotein cholesterol (LDL-C), the primary end point, as well as decreases in body-mass index (BMI) and smoking status and an increase in physical activity.

The automated, semipersonalized text messages offered support and advice on how to make lifestyle modifications.

"It was surprising that such a simple, low-cost intervention could be so effective in patients with coronary heart disease," lead author Dr Clara K Chow (University of Sydney, Australia) told heartwire from Medscape via email. "It perhaps spoke to the fact there was really a gap."

Chow noted that although patients are given a lot of information and advice at the time of an MI, these data often get lost during the stress of the situation.

"I think the texting support program we used in TEXT ME addressed this gap by providing bite-sized, digestible chunks of information to patients — and providing encouragement after they left the hospital," she said.

The findings were published in the September 22/29, 2015 issue of the Journal of the American Medical Association.

Missed Opportunity

"I am still surprised that many patients who have had a heart attack don't realize they are at such high risk of repeat heart attacks," said Chow. "Patients presenting with their first heart attack should be taking optimal prevention treatments, but many are not. This is really a missed opportunity."

She noted that she became interested in the potential of interventions for these patients "but found there was a lack of actual evidence of their benefit." Out of all this, the TEXT ME study was started.

Between September 2011 and November 2013, the investigators enrolled 710 patients (82% men; mean age 58 years) with CHD, defined as CHD proven by angiography or previous MI. All participants were randomly assigned to receive usual care alone (control group, n=358, 53.9% smokers) or with the lifestyle-modification texts (n=352, 52.3% smokers).

Usual care "generally included community follow-up, with the majority referred to inpatient cardiac rehabilitation, as determined by their usual physicians," report the researchers.

From a database of created messages, text messages were selected based on characteristics for each participant in the intervention group (such as smoking status) and sent out automatically through a computerized management system. The program wasn't interactive, but some of the messages did address the patient by name. For example: "Have you gone for your walk today, Jane?"

All messages were based on the Australian Heart Foundation Healthy Living Guidelines. In addition to clinical measurements, the Global Physical Activity Questionnaire, a carbon-monoxide–meter breath analyzer for smokers, and self-reports were used.

"Paints Possibilities"

At the end of 6 months, LDL-C was significantly lower for the text group (79 mg/dL, 95% CI 76–82 mg/dL) vs the control group (84 mg/dL, 95% CI 81–87 mg/dL; P=0.04).

The intervention group also had significantly lower systolic blood pressure (128.2 mm Hg vs 135.8 mm Hg, respectively) and BMI (29 vs 30.3), and fewer members who still smoked (26% vs 42.9%; all comparisons, P<0.001). Physical activity was significantly higher for the message group (936.1 MET min/wk vs 642.7 MET min/wk, respectively; P=0.003).

The investigators note that each message cost approximately US $0.10, for a total cost of $10 per participant for their 96 messages. In addition, 91% of the text-receiving group said that the messages were useful, and 97% said they were easy to understand. A total of 86% of the group said the frequency of messages received was appropriate.

However, "the duration of [the] effects and hence whether they result in improved clinical outcomes remain to be determined," write the investigators.

Still, Chow noted that the study demonstrates the potential of a low-cost texting strategy for reducing a combination of risk factors for repeat MIs in patients with CHD.

"While there are caveats—that is, we should see whether this works in diverse settings and whether the effects are prolonged—it paints the possibilities that really simple text-message–based strategies may have a real role and real health benefits to patients with chronic diseases," she said.

Influenced Behaviors, but More Work Needed

"The US healthcare system needs to be capable of testing novel low-risk interventions such as text messaging in the context of routine clinical care," write Drs Zubin J Eapen and Eric D Peterson (Duke Clinical Research Institute, Durham, NC) in an accompanying editorial[2].

"Creating an agile and clinically integrated research framework that rigorously evaluates all interventions . . . is a collective responsibility and challenge for both app developers and healthcare practitioners," they add.

The editorialists note that "solving this dilemma" can push the development and use of solutions to the global problem that is CVD.

"Well-conducted randomized clinical trials like TEXT ME demonstrate that mobile health interventions, even simple ones, can influence patient behaviors and improved risk profiles in the short term," write Eapen and Peterson. However, they add that it also shows that more work needs to be done.

"Healthcare insurers are unlikely to consider reimbursement for these novel interventions until there is good evidence that these approaches have clinical benefit and are generalizable."

The study was funded by grants from the national Heart Foundation of Australia and the Bupa Foundation. The study authors report no relevant financial relationships. Eapen reports serving on the advisory boards of Novartis, Amgen, and Cytokinetics; serving as a consultant for Novartis, Amgen, and SHL Telemedicine; and receiving honoraria from Janssen. Peterson reports receiving personal fees from Janssen, AstraZeneca, Boehringer Ingelheim, Bayer, Merck, Valeant, and Sanofi; and a grant from Janssen.

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