ORLANDO – A 12-week intervention involving a smartphone app and weekly coaching by telephone resulted in sustained, clinically meaningful improvement in multiple unhealthy diet and activity behaviors in the randomized, controlled Make Better Choices 2 study.

“It’s far more possible than I would have believed to produce sustained, large-magnitude changes in cardiovascular risk behaviors without using large financial incentives through the use of technologic support and a scalable approach to coaching,” principal investigator Bonnie J. Spring, Ph.D., said at the American Heart Association scientific sessions.

This is an example of what preventive medicine experts term “primordial prevention.” It’s intervention further upstream than primary prevention, which addresses the standard modifiable cardiovascular risk factors before a cardiovascular event has occurred. Primordial prevention addresses the unhealthy behaviors that eventually lead to the standard risk factors.

Make Better Choices 2 included 212 adults, all of whom had four unhealthy behaviors of interest: low fruit and vegetable intake, high consumption of saturated fat, low levels of moderate to vigorous physical activity, and excessive sedentary leisure TV and computer screen time.

The smartphone app was used for self-monitoring on the journey toward goal attainment. The data were uploaded regularly to the remote coach, who provided individualized instruction weekly for 3 months, then every 2 weeks during the next 3 months, and monthly for the final 3 months, explained Dr. Spring, professor of preventive medicine and director of the Center for Behavior and Health at Northwestern University, Chicago.

The study expanded upon the success of the earlier 204-subject Make Better Choices 1 study, which showed that targeting two of the four unhealthy behaviors resulted in efficiently synergistic improvement in all four (Arch Intern Med. 2012 May 28;172[10]:789-96). However, in the earlier trial, participants were paid $175 if they reached their goals. In Make Better Choices 2, Dr. Spring and her coworkers wanted to see if behavioral change could be achieved without a large financial incentive.

Make Better Choices 2 participants were randomized to one of three study arms: simultaneous targeting of fruit and vegetable intake, sedentary screen time, and low moderate to vigorous physical activity; sequential targeting of fruit/vegetables and screen time followed by the physical activity intervention; or a control group that received instruction on reducing stress and improving sleep.

The simultaneous and sequential interventions proved equally effective. And as in Make Better Choices 1, a carryover effect was seen: At 9 months, not only was fruit and vegetable consumption increased by 5.9 servings per day, compared with baseline and leisure screen time reduced by 2 hours and 7 minutes per day, but participants reduced their saturated fat intake by an absolute 3.7% of total calories consumed daily, even though saturated fat wasn’t targeted.

“We think the improvement in saturated fat intake was due mostly to cutting down on hand to mouth snacking behavior by decreasing TV time,” she explained.

Moderate to vigorous physical activity time was increased by an average of 16 minutes per day in the two active treatment arms, compared with controls at 6 months. However, at 9 months, there was no significant difference among the three groups.

“The hardest behavior change for us to initiate and maintain is moderate to vigorous physical activity. I think that warrants more research,” according to Dr. Spring.

Adherence was good, with roughly an 18% dropout rate through 9 months in each study arm.

Session moderator Dr. Sidney C. Smith of the University of North Carolina, Chapel Hill, noted that only about 25% of participants in the trial were men. He’s observed a similarly skewed ratio in other behavioral studies, and he wondered why, given that men have their acute MIs an average of 10 years earlier than women.

“This is a classic challenge in behavior intervention trials. It’s very difficult to get men to enroll,” Dr. Spring replied. “There’s starting to be a body of work trying to address this challenge.”

She added that she believes for some men it’s an issue of control. They want to do things their way, and they confuse support with control.

“This is one of the hopes of having technology available: If you’re a do-it-yourselfer, here are tools to help you do it yourself,” Dr. Spring said.

Once men get on board, however, a consistent finding in behavioral intervention studies is that the strategies work as well in men as in women, she observed.

Make Better Choices 2 was funded by Northwestern University and the National Institutes of Health. Dr. Spring reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

Smartphone app simultaneously improves multiple chronic disease risk behaviors