Left to Our Own Devices
The past decade has surely been the age of the app. A huge assortment of smartphone applications and wearable sensors have been developed. They have the potential to help people make healthier lifestyle choices.
But there is a difference between having the potential to help and actually helping. None of these apps or devices has been proven to change behavior or improve cardiovascular disease (CVD) outcomes. The American Heart Association published a statement looking at the current science on our use of mobile health (mHealth) technologies.
The writing group looked at peer-reviewed studies evaluating apps and devices aimed at managing weight, increasing physical activity, quitting smoking and controlling high blood pressure, high cholesterol and diabetes.
There was a wide range of mobile health tools and apps available. Exercise and weight loss had the most. Medication adherence had the fewest. Apps approach things in different ways. Some may be informational or motivational. Others may offer more interactive options such as self-monitoring, reminders and alerts.
Currently, one in five U.S. adults uses some technology to track health data. The most popular health apps are related to exercise, counting steps or heart rate. Mobile health can also include things like:
- text messages to combat the urge to smoke
- emails from lifestyle coaches
Many new apps and devices allow people to take a more active role in monitoring and managing their chronic conditions, therapeutic regimens and general health and wellness. But the current pace of science in evaluating these apps does not match the growth in consumer demand or industry’s rush to meet it.
The Food and Drug Administration only evaluates an app if it is part of a regulated medical device and most apps are not. Experts caution us that health apps may not use evidence-based content and are being used before their effectiveness is proven or disproven.
mHealth and Weight Management
Obesity and overweight are a big problem. They can either cause or contribute to CVD, Type 2 diabetes and depression. Individually or collectively, those conditions represent the leading causes of sickness and death in the United States. A sustained weight loss of 3 percent to 5 percent for anyone not at their ideal weight can delay or even prevent diabetes. It can also improve other CVD risk factors like high blood pressure (HBP).
Healthy weight management combines three things:
- calorie-controlled, healthy eating
- increased physical activity with specified goals
- behavioral strategies (i.e., self-monitoring, personalized feedback and social support from coaches)
Studies used a range of mHealth, including texting (SMS), smartphone applications, handheld personal digital assistants (PDAs) and interactive voice response (IVR) systems. The AHA writing group also discussed many network-connected devices, including e-scales and wireless physical activity monitoring devices.
There was moderate evidence that it is helpful to use electronic devices to deliver comprehensive lifestyle programs with personalized feedback from a trained interventionist, such as calls or messages from a coach.These electronically delivered interventions are an acceptable alternative to in-person feedback and support, but they are not as effective.
mHealth and Physical Activity
Other studies have reported that Americans have become more sedentary in the past few decades. From 1960 to 2008, there has been a steady increase in jobs that are sedentary or require only light-intensity physical activity. Jobs requiring moderately-intense physical activity have decreased from 48 percent in 1960 to 20 percent in 2008. During this time, the amount of calories burned on the job daily dropped by 140 for men and 124 for women.
The AHA group reviewed studies using mHealth to monitor physical activity. Nine out of 14 trials that used an intervention group and a control group reported significant increases in activity for those who used mHealth technology. The technology most often used was the Internet, making use of websites, online tutorials or networking. One of the 14 studies used text messaging to send a motivational text three times a day, three days a week for six weeks. It reported significant differences between the intervention and control groups. Two more studies looked at messages delivered through a PDA or email and reported increasing activity levels.
Most studied mHealth interventions allow users to self-monitor. However, more sophisticated wearable devices are becoming widely available for self-monitoring daily activity such as pedometers, smartwatches and other activity trackers you wear on your body. Many new smartphones contain motion and speed sensors that provide the same kind of information as wearables. There are many apps that use these sensors. Some mobile operating systems have built-in physical activity tracking. We’re beginning to see evidence that combining activity tracking with group behavioral treatments produces better outcomes than either the device or group treatment alone.
Gaming devices, like the Wii, have grown in popularity and acceptance. The soundness of available studies of active gaming is limited, so the AHA writing group did not look at those. But a previous review of several laboratory studies supported that this type of gaming can provide light-to-moderate physical activity. Only three studies found it effectively increased physical activity or exercise attendance.
mHealth and Smoking Cessation
Early mHealth smoking cessation programs used the Internet to assist smokers in quitting. Some of these programs are still available and continue to provide smoking cessation assistance such as smokefree.gov. Mobile technologies provide potential advantages for smoking cessation. For instance, they can offer features that, based on time of day or where you are, can anticipate when you may want to smoke and alert you to stay committed to not lighting up.
Smoking cessation apps are a relatively new area of research with only 10 years of published studies. Even within that time, a number of studies have shown that text-messaging programs produce about double the quit rates compared to minimal intervention. Despite this success, about 90 percent of participants fail to quit at six months. Until more is known, current research supports consideration of texting interventions as an add-on to other proven smoking cessation programs.
mHealth and Diabetes
Controlling blood sugar requires problem solving and daily decision making about eating, activity, glucose monitoring and medication taking. It’s also important for patients to be in regular communication with a doctor so they can work to prescribe the best medication(s) and monitor the impact of them.
There are thousands of apps for supporting diabetes self-management, serving mostly as tracking and reference tools. Few have been evaluated, and even fewer have demonstrated outcomes. In fact, less than one percent have been studied.
MHealth technologies for diabetes self-management fall into three categories:
- text-message apps via mobile phones
- medical devices such as glucose meters that are connected to smartphone apps
- apps that share data between patients and providers
There aren’t many large randomized controlled trials of these apps. Smaller studies have looked at them and have identified these essential components of a successful app: personalized engagement; feedback the patient can do something about; and connection to healthcare providers.
Several studies showed good results for improving glucose control, but none of the studies went on for very long with many lasting only three months. Given the short timeframes, it is uncertain whether the apps were responsible for any change in glucose levels. After all, a 2011 survey found that a quarter of downloaded health apps in general were used only once. Three quarters of them were used no more than ten times.
mHealth and Blood Pressure
High blood pressure (HBP) is widespread, chronic and a major risk factor for CVD. Best practices for treating it combine drug therapy and lifestyle counseling for exercise, healthy eating and smoke-free living.
MHealth technology offers an opportunity to improve access to HBP care. People spend a few hours a year with a physician or nurse, but we spend 5,000 waking hours each year making choices that affect our health.
Self-measured BP (SMBP) monitoring seems to be beneficial. It is recommended as part of HBP management and for seeing if a treatment is working and if patients are following their treatment plans.
The panel focused on things that offered something beyond simply self-monitoring, like adding support to the patients’ usual care. Among the best studies that focused on SMBP plus usual care, there was a net reduction in systolic BP of between 2.1 mm Hg to 8.3 mm Hg.
Even though most studies lasted less than six months and none lasted longer than a year, they showed promise. However, because HBP is chronic, the panel recommended longer-term investigation.
mHealth and Cholesterol
Between 10 percent and 20 percent of Americans have high cholesterol, which contributes to atherosclerosis.
Research has shown that educating patients about their condition and self-management can help. Promising tools are starting to be available for managing high cholesterol. These include home lipid testing with a smartphone, educational apps and Web portals for patients and their providers. Although evidence suggests some benefit to these apps, there isn’t much available on this yet.
The number of apps will continue to grow and it will be important to study whether they can be effective at achieving the outcomes they were developed to address.
Because this is a relatively new field, there is little to no data on whether patients continue to use mHealth long term — an important consideration given the chronic nature of conditions such as HBP and diabetes. Though apps show promise for the treatment and prevention of CVD, right now there is a lack of data backing up their claims.
Lora E. Burke, Ph.D., M.P.H., lead author of the statement and professor of nursing and epidemiology at the University of Pittsburgh had this to say: “The fact that mobile health technologies haven’t been fully studied doesn’t mean that they are not effective. Self-monitoring is one of the core strategies for changing cardiovascular health behaviors. If a mobile health technology, such as a smartphone app for self-monitoring diet, weight or physical activity, is helping you improve your behavior, then stick with it.”
This information is provided as a resource to our readers. The tips, products or resources listed have not been reviewed or endorsed by the American Heart Association.