App Plus Coaching Can Change Four Heart-Health Habits at Once

Marlene Busko

November 12, 2015

ORLANDO, FL — In the 9-month Make Better Choices 2 (MBC2) trial, participants who used an app and received coaching aimed at improving diet and exercise habits attained important improvements in behaviors that affect risk of cardiovascular disease[1]. Moreover, it didn't matter if the participants tried to change several behaviors at once or only one at a time.

"We saw about a 2-hour reduction in TV [and computer] screen watching, a six-serving-per-day increase in [intake of] fruits and vegetables, a 3.7% reduction in saturated-fat [intake], and about a 15-minute increase in moderate/vigorous physical activity," Dr Bonnie Spring (Northwestern University Feinberg School of Medicine, Chicago, IL) reported in a press briefing here at the American Heart Association (AHA) 2015 Scientific Sessions. A control group that received an app and coaching about managing stress levels did not have these diet and exercise improvements.

"The implications are that it's far more possible than I would have believed to produce sustained, large-magnitude improvements in cardiovascular risk behaviors without using large financial incentives," Spring said.

To heartwire from Medscape, she added that apps "are proliferating and consumers are using them, and the [US Food and Drug Administration] FDA very wisely has taken a stance that they don't want to stifle innovation," so the apps are not classed as medical devices. However, commercial apps that are not based on clinical-trial data may not be effective for altering behaviors. "We may not be able to develop things that are as glitzy as industry might develop, but we base them on behavior-change principles, so we know they work," she said.

Session cochair Dr Donald M Lloyd-Jones (Northwestern University Feinberg School of Medicine), who was not involved with this trial, told heartwire that the "data suggest you need . . . not just the app, but the backup coaching. But as we get smarter about how to design these things, our phones start to sass back at us, and maybe the phone will start to coach us. Who knows?"

Fix Diet First, Then Exercise More, or Do Both Together?

People commonly have several poor diet and physical-activity habits, which put them at increased risk of CVD and other disease. But the problem is, "how can we manage to help people change [multiple behaviors] without getting them overwhelmed?" Spring said.

In an earlier study, MBC1[2], the researchers enrolled 204 individuals with four health-behavior shortcomings. The study participants ate fewer than five servings of fruits or vegetables a day; received >8% of their caloric intake from saturated fat; performed less than 1 hour of moderate/vigorous physical activity a day; and spent more than 90 minutes a day in sedentary leisure activity (eg, watching TV, searching the internet, or playing video games).

The participants recorded their food intake on a Palm Pilot and wore an accelerometer that measured their activity level, and the data were transmitted to a behavior coach. They received $175 if they met certain target goals. However, "even after we stopped paying them to perform these behaviors, they maintained about half of the improvement, which very much surprised us," Spring reported.

When the study subjects increased their fruit and vegetable intake, they automatically reduced their saturated-fat intake, she noted.

The current MBC2 trial investigated whether an app plus coaching aimed at improving diet and activity levels would be better than a control intervention, and second, whether changing multiple behaviors is better done all at once or sequentially.

Spring and colleagues randomized 212 adults with the four health-risk behaviors studied in the earlier trial into:

  • 44 participants (control intervention group) who received an app for stress management.

  • 84 participants (sequential intervention group) who at first received an app for recording food intake and sedentary behavior only.

  • 84 participants (simultaneous intervention group) who received an app for recording food intake, sedentary behavior, and exercise, at the same time.

As in the earlier trial, participants wore a wireless accelerometer. They received calls from a behavior coach once a week for 3 months, followed by maintenance calls every 2 weeks for 3 months and once a month for 6 to 9 months.

The app has two circles like odometers, which light up and reflect how well a person is meeting their target goals, Springer explained. "We're very responsive to feedback . . . and the app gives it to us." During the initial 3 months, participants had access to online lesson plans that they could review with the behavior coach at the weekly phone calls, and the coach would have the data from the person's device, so he or she could provide tailored encouragement.

The dropout rate was 16% and was similar across the three groups.

The sequential and simultaneous treatments produced equally large, sustained healthy changes in diet and activity.

However, whereas at 6 months, the participants in the intervention groups had higher rates of physical activity than those in the control group, at 9 months the rates of exercise were similar in all 3 groups—but this was because participants in the control group began exercising more.

The basic principles are that patients need something that gives them a very visible goal, causes them to self-monitor, and gives them feedback, according to Spring. Then they need some social support. If they can't get it from a coach, they can join a support group or talk to their clinician, she added.

"While we think . . . smartphone apps might be something that is useful," Spring actually demonstrated that it can be very useful in implementing sustainable behavior change, Lloyd Jones said.

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