Design & Evaluation of Mobile Technology for Health Behavior Change

1. Design & Evaluation of Mobile Technology for Health Behavior Change Greg Norman, PhD Department of Family & Preventive Medicine University of California, San Diego

2. Center for Wireless & Population Health Systems

3. Center for Wireless & Population Health Systems • Kevin Patrick, MD • Greg Norman, PhD • Jacqueline Kerr, PhD • Linda Hill, MD • Jeannie Huang, MD • Simon Marshall, PhD • Cheryl Rock, PhD • James Fowler, PhD • Karen Calfas, PhD • Bill Griswald, PhD

4. Center for Wireless and Population Health Systems Research on systems of wireless, clinical, and home technologies to measure and improve lifestyle and other health-related behaviors in: -- Healthy adolescents -- Overweight and obese children and adults -- Depressed adults -- Adolescents risk for type 2 diabetes -- Adolescents with chronic disease -- Older adults to promote successful aging -- Adolescents recovering from leukemia -- Young adults to prevent weight gain -- Adults with schizophrenia -- Exposure biology research -- Cancer comparative effectiveness research CWPHS.UCSD.EDU

5. Intervention & Methodology • Expert Systems • Kiosks • Interactive Websites • SMS Mobile Phones • Exergames • Mobile Apps • Measure Development • Classification • Longitudinal Data Analysis • Randomized Controlled Trials • Mediation & Moderation • Geographic Information Systems (GIS) mHealth = Integrates intervention & measurement systems

6. Overview: SMS Text Messaging Intervention for Weight Loss SMART: Social/Mobile Approach to Reduce WeighT

7. Problem • Trend of increasing obesity. • Behaviors that can impact obesity include physical activity, sedentary behavior, and dietary behaviors. • Need for effective approaches to obesity prevention and treatment.

8. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1999 1990 2009 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Behavioral Risk Factor Surveillance System, CDC.

9. Rational for Mobile Interventions moderate to vigorous activities: 0.7 hours/day Context relevant Point of decision Just in time On the go Convenient Unobtrusive sedentary time: 9.3 hours/day light-intensity activities: 6.5 hours/day Wireless Technologies Data Analytics * Persuasive Design

10. Body Sensor Network

11. Social Networks

12. Geographic Information Systems (GIS) & GPS data • Parks • Distance & density & acreage • Schools • Distance & density • Recreation Facilities • Distance & density • 2010 Census data • Housing unit density • Parcel & Land Use • Commercial, industrial, institutional, residential, office, open space, vacant • Retail parcel count • CoStar / SD County Tax Assessor • Retail floor area ratio • Coastline • Distance to coast • Local & Major Roads • Intersection & cul-de-sac counts

13. mDIET & ConTxt Mobile Diet Intervention through Electronic Technology PURPOSE Randomized Clinical Trials to evaluate the use of Text Messages (SMS) to improve dietary behaviors and weight outcomes in obese men and women.

14. mDIET:mobile Dietary Intervention through Electronic Technology Funded by the National Cancer Institute R21 CA115615-01A1 Resulted in the first report in the literature of an RCT evaluating SMS/MMS for weight loss

15. mDIET: Study Design & Sample Randomized Controlled Trial: Participants were randomized to either an Intervention (mDIET) or Control group (usual care). Completed 3 in-office measurement visits over a 4 month period • Sample N = 63 • 81% Women • Mean age 45.9 years • Women ranged 26 – 55 yrs. • Men ranged 33 – 55 yrs. • Race/Ethnicity • 76.2% Caucasian or White • 15.9% African American or Black • 3.2% Asian American/Pacific Islander/Native Hawaiian • 4.8% Prefer not to state • 22.2% Hispanic

16. mDIET Components • Daily Text & Picture Messages • Participant could choose the # of messages to receive & times to receive the messages • (2-5 messages per day) • Daily messages are statements or questions • Printed Materials for recommended weekly reading • Behavioral Skills, Nutrition, and PA topics (e.g. Self-monitoring, Portion Control, Routine Physical Activity) First half provided in Binder at baseline; Second half provided at mid-point measurement visit; participants were given a pedometer • Monthly Brief Counseling Calls (5-10 minutes) • Progress and counseling calls from their Health Coach addressing strategies, • social support, problem solving, etc. • Goals • Primary: Daily 500 calorie deficit (through calorie reduction and an increase in calories burned by reaching and maintaining a 12,000 steps/day goal) • Self-Monitoring • Weekly weigh in (text weight) and daily food & exercise journal

17. Types of mDIET Messages

18. Personalized Text Messages • Eating Behaviors • 4 items on the EBI were emphasized (based on our own logic rules) • Name • Some text messages included their first name (e.g. Congrats, Maria! You continue to improve. You're clearly working hard and it shows). • Grocery Store • Participants were asked to identify the grocery store that they most frequently visit (e.g. Did you buy fruits and vegetables from Trader Joes this week?) • Social Supporter • Participants were asked to identify someone in their personal life (family member, friend, co-worker) that could part of their social support system (e.g. Have you been telling Mark about your weight loss success?)

19. Message Activity

20. How mDIET Works… 3000 Messages 1500 Intervention Rules Time of Day / Day of Week ?User’s Week in Program ?Previous Messages ?Previous Replies ?User EBI ?......... Time of Day Sender SMS Out Client Management System User Database Receiver SMS In ASP Web-pages MS/SQL Database Java Application Mail Gateway

21. mDIET: Results Mobile Diet Intervention through Electronic Technology

22. Participant Feedback on mDIET “Steady reminder – keeping health on my mind” “Felt commitment every day – could not let myself forget my goals” “They served as an excellent reminder to watch what I ate” “Keeps me focused” “Constant reminders to believe in myself and make the right choices” “I found that texting your weight every week was extremely helpful” “I miss my 6am message!” Overall satisfaction with mDIET program for weight loss 95.6% of participants would recommend mDIET to friends/family

23. ConTxt • PURPOSE • To develop and test the efficacy of a SMS intervention for weight loss among overweight and moderately obese (BMI 27-39.9) men and women ages 21–60.  • The ConTxtstudy builds upon our work with pilot SMS weight loss study mDIET. • The ConTxtstudy aims to expand the logic of the SMS messages and ecological components for over 300 English-speaking participants and Spanish-speaking participants. 

24. ConTxt Team & Support Staff Investigators

25. RCT Study Design • RCT ERNROLLMENT BEGAN: October 2011 • Community Recruitment: Email listservs, flyers, community events, print and/or radio advertisements 309 Subjects, 21-60 years old male & female, Weight: 27 <BMI <39.9 English & Spanish speaking Text Messages Users (or willing to learn) n = 103 Comparison n = 103 SMS Only n = 103 SMS Only + Counseling

26. Control/Comparison • Standard of Care Information via printed materials: • Diet/Nutrition • Physical Activity • General Health • Monthly mailings • 4-Month opportunity to “cross-over” and receive 4-months of the ConTxt intervention AFTERcompletion of 12-month assessment.

27. Intervention Components • Weekly printed materials on core behavioral and weight loss strategies • Daily SMS messages: • TAILORED MESSAGES: weight loss/management strategies; goal setting; behavioral barriers; weight monitoring; skill mastery; physical activity; and location • PERSONALIZED MESSAGES: name; location; social supporter; grocery store; children/pets • STANDARD MESSAGES: weight loss strategies; self monitoring SMS + COUNSELING CALLS Receive bi-weekly and monthly counseling calls to assess progress, skill development, and barriers

28. ConTxt: 16-Week Cycle Topics 1. Self-monitoring & Goal Setting 2. Calories 3. Meal Planning 4. Pedometers & CV Exercise 5. Portion Control 6. Sedentary Time 7. Barriers 8. Routine PA 9. Eating Out 10. Managing Social Situations 11. Vigorous PA 12. Substitution 13. Healthy on a Budget 14. Strength & Stretching 15. Body Image 16. Sticking with It

29. Weight Behavior Inventory (WBI) • Shopped when I was not hungry. • Shopped from a list. • Stored food in containers where it was not readily visible or in a closed cabinet. • Kept healthy ready-to-eat or portion controlled snacks for myself. • Removed high calorie foods from my home, office or room. • If I was served too much, I left food on my plate. • Only ate when I was hungry. • Decided ahead of time what I would eat for meals and snacks. • Reduced portion sizes. • Changed food preparation techniques. • Left a few bites of food on my plate. • Followed a structured meal plan. • Recorded or wrote down the type and quantity of food eaten. • Avoided eating while watching TV. • Reduced my calorie intake. • Cut out/reduced sweets or junk food. • Cut out/reduced between meal snacks. • Cut out/reduced late night snacking. • Ate less meat. • Ate less fat. • Drank less alcohol or changed type of drink to reduce calories. • Increased fruits and vegetables. • Used frozen entrees such as Lean Cuisine or Smart Ones. • Decreased frequency or portion sizes of desserts. • Altered my daily routine to get more lifestyle physical activity. • Used the stairs instead of the elevator. • Wore a pedometer. • Reduced the amount of time spent watching TV. • Used home exercise equipment. • Exercised at a gym or participated in an exercise class. • Worked out with a personal trainer. • Exercised for period of 30 minutes or more. • Recorded or graphed my physical activity. • Weighed myself regularly or daily. • Recorded or graphed my weight.

30. Types of Text Messages

31. Types of Text Messages

32. SMS Logic & Flow Weekly Mastery Assessment (Friday) Sunday Weekly WBI Messages • Send SMS: • “On a scale of 1 (never) to 5 (always), how often did you [insert WBI] in the past week?” Willingness Send SMS: “Are you willing to set goals for [WBI] this week? (y/n)” Barrier SMS Messages (M, T, W, TH, SA) Mastery = Weekly Average (after 3 weeks) >/= to 4 YES NO Answer 4 or 5 Answer 1, 2, or 3 Knowledge Text Messages Skills/ Tips Text Messages Send Multiple Choice Barrier Question • Barrier 1 • Barrier 2 • Barrier 3 • Barrier 4 WBI Maintenance Messages (M, T, W, TH, SA)

33. Tagging Text Messages

34. Tagging Text Messages Examples

35. User Ratings of Messages 58 randomized to SMS have been in the program for 0 to 17 weeks. 36 rated at least one message. Number of messages an individual rated ranged from 0 to 144, mean 13.8, sd = 23.6, median = 4. 327 messages have been rated 1 to 16 times

36. User Ratings of Text Messages

38. PURPOSE To leverage mobile phones, social networks,and the web for weight loss among 18-35 year old young adults. Funded with a 5-year grant from NHLBI/NIH. SMART: Social/Mobile Approach to Reduce WeighT

39. SMART Study Team 39

40. SMART Study Design 400 Subjects, 18-35 years old male & female, Weight: 25 < BMI < 34.9 University students at three colleges in the San Diego area • Owns a personal computer • Owns a mobile phone and uses text messaging • Facebook user / willing to start using Facebook • ENROLLMENT Began: June 2011 n = 200 Comparison n = 200 Treatment PRIMARY AIM: At least 5-10% weight loss at 24 months

41. Study Population: College Students

42. Study Outcomes Primary outcome - Weight status at 24 months • Secondary outcomes - • Weight status at other time points • PA/Diet/Sedentary/Sleep • Quality of life • Depression • Use of technologies & relationship to outcomes

43. SMART Group A vs Group B Group A - Interactive Technology vs. Group B - “Self-guided” Group A Interactive Weight-loss Program Group B Self-guided Weight-loss Program • Tools: Binder with introductory program materials, scale, pedometer • 15-min “greeter session” • 30-min in-person kick-off session • 10 “lifelines” cashed in for virtual (Skype) face time or phone calls over a 24-month period • Problem solving around barriers • Mobiles apps • Social support via Facebook • Email • Text messaging • Behavioral recommendations • Decrease daily calorie intake by 500-1000 cal/day • Increased PA by 10% until at 60min/day and 80% of target HR • Knowledge – Content on TTM website • Focus on five core behaviors • Paid incentive for measurement visits • Binder with introductory “program” materials • Monthly website topics • Weekly health tips • Weekly online polls • Paid incentive. 43

44. Comparison Condition • Standard of Care information via a static website:www.smarthealthtools.com • Weekly emails: • introduction to monthly health-related topic first week of each month • a health tip every second week • a health events calendar every third week • a poll question on website every fourth week • Consent via Facebook but no further interaction on Facebook

45. 1 - Participant 2 - Friend of Participant SMART 3 - Friend of Friend Social Mobile Approaches to Reduce Weight SMART Study Facebook an intact social network

46. A “User-centered” Intervention Web Smart- phone Apps Be sure to check your email for this this week’s topic from ThreeTwoMe Mobile Txt Msgs Email Other Tools Bathroom Scale Pedometer

47. Intervention: Health Coach Session SMART: Social Mobile Approaches to Reduce Weight 15-min greeter session 30-min in-person health coach visit 10 “lifelines” Up to 15-min each Can be used from month 2 through month 24 • Before the visit: send questionnaire for “getting to know you” • 30-minute Health Coach focus: • Communicating SMART study goals: 5-10% weight loss; 500-1000 calorie deficit per day; increase physical activity: 0  10% gradually  moderate to vigorous intensity exercise for 60 min/day (calculate target HR) • Set personal goals for subject. How much weight loss do they want to achieve? • Focus on: motivation, readiness, current behaviors, lifestyle, current knowledge of WL behaviors, practices, issues, problems, behaviors • Focus on orienting them to the study; how to use the study and the study tools (apps, FB, social support) • Convey key messages: • We want to hear from you whether you’re losing or gaining weight. We’re here to help you. • We know from other studies that people who interact with study tools tend to be more successful. • In order for you to be in the study, you must be willing to do this. • You have to interact everyday. Some things will work for you; others won’t. • We have many tools. Find the tools that work for you. • If you’re not losing weight, use your ‘lifeline’ and contact your health coach. • 10 Lifelines for “emergencies” or if they “fall off the wagon”. 47

48. Intervention: Web SMART: Social Mobile Approaches to Reduce Weight ThreeTwoMe Term for the SMART intervention Developed as a unique “brand” www.threetwome.com • 16 weekly topics in blocks of six • Deeper dive on each topic • “Homework” for each topic via “Practice it”. 48

49. Intervention: Web SMART: Social Mobile Approaches to Reduce Weight ThreeTwoMe Term for the SMART intervention Developed as a unique “brand” www.threetwome.com